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The Shoulder
Imaging Diagnosis
with Clinical Implications
Jenny T. Bencardino
Editor
123
The Shoulder
Jenny T. Bencardino
Editor
The Shoulder
Imaging Diagnosis with Clinical
Implications
Editor
Jenny T. Bencardino
Penn Medicine Department of Radiology
Perelman School of Medicine at the
University of Pennsylvania
Philadelphia, PA
USA
ISBN 978-3-030-06239-2 ISBN 978-3-030-06240-8 (eBook)

https://doi.org/10.1007/978-3-030-06240-8
© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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Acknowledgements
The art of publishing involves the orchestrated work of many individuals. The
journey as the editor of The Shoulder: Imaging Diagnosis with Clinical
Implications has been both inspiring and rewarding thanks to the outstanding
contributions found in this book by so many renowned experts in the field of
musculoskeletal imaging.
I am very grateful to Dr. Monica Tafur for her invaluable assistance in the
preparation of this manuscript.
Dr. Luis S. Beltran is the mastermind behind the high-quality original
illustrations found in this page and in the chapters devoted to the biceps ten-
don, rotator interval and glenohumeral instability.
I am also very thankful to Springer, in particular to Reshmi Rema, for see-
ing our project through to completion.
My utmost gratitude goes to my dearest husband Alvand and my sons
Dario and Avan for their patience and unwavering support through the years
that took to bring this book to fruition.
v
Contents
Part I Imaging Techniques
1 Current Protocols for Radiographic and CT

Evaluation of the Shoulder�� 3
Joyce H. Y. Leung and James F. Griffith
2 Technical Update in Conventional
and Arthrographic MRI of the Shoulder�� 23
Seema Meraj and Jenny T. Bencardino
3 Sonographic Evaluation of the Shoulder �� 55
Avner Yemin and Ronald S. Adler
4 Image-Guided Procedures of the Shoulder �� 67
Ogonna Kenechi Nwawka, Shefali Kothary,
and Theodore T. Miller
Part II Rotator Cuff, Biceps and Rotator Interval
5 Imaging Diagnosis of Rotator Cuff Pathology

and Impingement Syndromes �� 87
Eric Y. Chang and Christine B. Chung
6 Imaging Diagnosis of Biceps Tendon and Rotator
Interval Pathology�� 127
Luis S. Beltran, Eric Ledermann, Sana Ali, and Javier Beltran
Part III The Labrum
7 Imaging Diagnosis of Glenohumeral Instability

with Clinical Implications �� 147
Luis S. Beltran, Monica Tafur, and Jenny T. Bencardino
8 Imaging Diagnosis of SLAP Tears and Microinstability�� 167
Konstantin Krepkin, Michael J. Tuite,
and Jenny T. Bencardino
vii
viii Contents
Part IV Trauma and Arthropathies
9 Imaging Diagnosis of Shoulder Girdle Fractures �� 191

Joseph S. Yu
10 Imaging Diagnosis of Shoulder Arthropathy�� 211
Mingqian Huang and Mark Schweitzer
11 Preoperative Planning and Postoperative Imaging
of Shoulder Arthroplasty�� 247
Jonelle Petscavage-Thomas
Part V Miscellaneous
12 Imaging Diagnosis of Tumors and Tumorlike

Conditions of the Shoulder�� 269
Eric A. Walker, Matthew J. Minn, and Mark D. Murphey
13 Imaging of Pediatric Disorders of the Shoulder�� 301
Jorge Delgado and Diego Jaramillo
14 Imaging Diagnosis of Nerve Entrapments in the Shoulder�� 321
Alireza Eajazi, Miriam A. Bredella, and Martin Torriani
Contributors
Ronald S. Adler Department of Radiology, New York University Langone

Health, New York, NY, USA
Sana Ali Department of Radiology, Maimonides Medical Center, Brooklyn,
NY, USA
Javier Beltran Department of Radiology, Maimonides Medical Center,
Brooklyn, NY, USA
Luis S. Beltran Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, MA, USA
Jenny T. Bencardino Department of Radiology, New York University
Langone Health, New York, NY, USA
Penn Medicine, Department of Radiology, Perelman School of Medicine at
the University of Pennsylvania, Philadelphia, PA, USA
Miriam A. Bredella Division of Musculoskeletal Imaging and Intervention,
Department of Radiology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
Eric Y. Chang Department of Radiology, VA San Diego Healthcare System,
San Diego, CA, USA
Department of Radiology, University of California, San Diego Medical
Center, San Diego, CA, USA
Christine B. Chung Department of Radiology, VA San Diego Healthcare
System, San Diego, CA, USA
Department of Radiology, University of California, San Diego Medical
Center, San Diego, CA, USA
Jorge Delgado Department of Radiology, Massachusetts General Hospital,
Harvard Medical School, Boston, MA, USA
Alireza Eajazi Division of Musculoskeletal Imaging and Intervention,
James F. Griffith Department of Imaging and Interventional Radiology,
Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT,
Hong Kong
ix
x Contributors
Mingqian Huang Department of Radiology, Stony Brook University

Hospital, Stony Brook School of Medicine, Stony Brook, NY, USA
Diego Jaramillo Department of Radiology, Columbia University Medical
Center, New York, NY, USA
Shefali Kothary Division of Ultrasound, Department of Radiology and
Imaging, Hospital for Special Surgery, Weill Medical College of Cornell
University, New York, NY, USA
Konstantin Krepkin Department of Radiology, New York University
Eric Ledermann Department of Radiology, Maimonides Medical Center,
Brooklyn, NY, USA
Joyce H.Y. Leung Department of Imaging and Interventional Radiology,
The Chinese University of Hong Kong, Shatin, NT, Hong Kong
Seema Meraj Zwanger-Pesiri Radiology, Lindenhurst, NY, USA
Theodore T. Miller Division of Ultrasound, Department of Radiology and
Imaging, Hospital for Special Surgery, Weill Medical College of Cornell
University, New York, NY, USA
Matthew J. Minn American Institute for Radiologic Pathology, Silver
Spring, MD, USA
Mark D. Murphey American Institute for Radiologic Pathology, Silver
Spring, MD, USA
Departments of Radiology and Nuclear Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD, USA
Walter Reed Army Medical Center, Washington, DC, USA
Ogonna Kenechi Nwawka Division of Ultrasound, Department of
Radiology and Imaging, Hospital for Special Surgery, Weill Medical College
of Cornell University, New York, NY, USA
Jonelle Petscavage-Thomas Department of Radiology, Penn State Milton
S. Hershey Medical Center, Hershey, PA, USA
Mark Schweitzer Department of Radiology, Stony Brook University
Hospital, Stony Brook School of Medicine, Stony Brook, NY, USA
Monica Tafur Department of Radiology, Michael’s Hospital, University of
Toronto, Toronto, ON, Canada
Martin Torriani Division of Musculoskeletal Imaging and Intervention,
Michael J. Tuite Department of Radiology, University of Wisconsin School
of Medicine and Public Health, Madison, WI, USA
Contributors xi
Eric A. Walker Department of Radiology, Milton S. Hershey Medical

Center, Hershey, PA, USA
Departments of Radiology and Nuclear Medicine, Uniformed Services
University of the Health Sciences, Bethesda, MD, USA
Avner Yemin Envision Physician Services—Radiology Associates of
Hollywood, Memorial Healthcare System, Hollywood, FL, USA
Joseph S. Yu Department of Radiology, The Ohio State University Wexner
Medical Center, Columbus, OH, USA
Part I
Imaging Techniques
Current Protocols for Radiographic
and CT Evaluation of the Shoulder 1
Joyce H.Y. Leung and James F. Griffith
1.1 Shoulder Pain in clinical practice are rotator cuff tendinosis and
subacromial-subdeltoid bursitis, rotator cuff
Shoulder pain is one of the most common muscu- tears, biceps tendinosis and tears, calcific tendini-
loskeletal symptoms and a frequent indication for tis, superior labral tears, adhesive capsulitis, and
musculoskeletal imaging. Shoulder pain, com- acromioclavicular joint arthritis. These entities
pared to pain in smaller joints such as the elbow, account for over 95% of patients with shoulder
wrist, or ankle, is usually not well localized and pain. Radiographs and computed tomography
even when it is well localized may not necessar- (CT) are not the primary imaging modalities used
ily correlate closely with the site of the pathol- to evaluate these specific pathologies, which are
ogy. There is considerable overlap in the clinical best visualized by ultrasound and magnetic reso-
presentation of common shoulder conditions nance imaging (MRI). Nevertheless, radiographs
such as rotator cuff tendon tear, subacromial- are still the primary imaging modality used to
subdeltoid bursitis, calcific tendinitis, superior investigate a patient with shoulder problems.
labral tears, and adhesive capsulitis. The most This is testament to the ease of availability of
likely reason for poor localization of shoulder radiographs and their ability to provide a good
pain is the expansive nature of the two main pain overview of shoulder anatomy and pathology as
generators in the shoulder, namely the well as helping to quickly exclude several serious
subacromial-subdeltoid bursa and the shoulder shoulder pathologies such as tumor, dislocation,
joint synovium/capsule. or fracture.
This poor localization of shoulder pain clearly
has implications for shoulder imaging since one
has to consider a range of potential etiologies in 1.2 Radiography
most patients referred for imaging with shoulder
pain. The most common causes of shoulder pain Standard radiographic views of the shoulder are
still very widely obtained. However, since the
1990s, with the emergence of supplementary
J. H.Y. Leung
Department of Imaging and Interventional Radiology, imaging investigations (ultrasound, CT, MRI),
The Chinese University of Hong Kong, specialized radiographic views of the shoulder
Shatin, NT, Hong Kong are less frequently obtained. Increasingly, the
J. F. Griffith (*) tendency is to obtain an alternative investigation
Department of Imaging and Interventional Radiology, to show and grade features previously investi-
Prince of Wales Hospital, The Chinese University gated by radiography such as Hill-Sachs defor-
of Hong Kong, Shatin, NT, Hong Kong
e-mail: griffith@cuhk.edu.hk mity, or glenoid bone loss. This trend is
© Springer Nature Switzerland AG 2019 3

J. T. Bencardino (ed.), The Shoulder, https://doi.org/10.1007/978-3-030-06240-8_1
4 J. H.Y. Leung and J. F. Griffith
understandable and likely to continue, since in and scapula (Fig. 1.1d–f). The lateral border of
most instances these alternative investigations the scapula and medial cortex of the proximal
(US, CT, MRI) show the abnormality more reli- humerus forms a smooth arch known as scapulo-
ably and to better effect than radiographs and humeral arch or Moloney’s line. This is analo-
also provide clinically relevant information on gous to Shenton’s line of the hip. The
adjacent soft-tissue structures. Specialized radio- acromiohumeral interval can also be seen. This
graphic views are technically more difficult to should normally be >7 mm. Superior migration
obtain especially in the acute trauma setting of the humeral head which is a feature of severe
though also in the more chronic setting if there is rotator cuff tears, particularly of the supraspina-
limitation of shoulder movement. The net effect tus tendon, leads to disruption of the scapulo-
is that one encounters specialized views of the humeral arch and narrowing of the
shoulder much less frequently than previously. acromiohumeral interval.
As a consequence, when specialized views are One can also appreciate that there is normally
requested, the technological nuance to achieve a a slight overlap between the glenoid rim and the
high-quality specialized view is not always read- humeral head as the glenohumeral joint is nor-
ily available. mally tilted anteriorly by about 40°. As the pro-
jection is not tangential to the glenohumeral
joint space, this joint space is not seen in profile.
1.2.1 Common Radiographic Views The anteroposterior view is particularly good for
of the Shoulder showing fractures of the proximal humerus,
scapula, or clavicle (Fig. 1.1g–i), for showing
1.2.1.1 Anteroposterior (AP) View dislocation of either the glenohumeral (Fig. 1.1j,
This is the most common, and often the only, k) or the acromioclavicular joints. It is also help-
view obtained when screening for shoulder ful for showing rotator cuff calcific tendinitis
pathology. It is the easiest to perform, even in the (Fig. 1.1k) or acromioclavicular joint arthritis.
setting of severe trauma. The AP view in internal rotation can show up to
92% of Hill-Sachs deformities [1], though not in
Technique (Fig. 1.1a–c) the same detail as axillary or Stryker notch
Patient Position: views.
–– Standing or supine.
–– Coronal plane of body parallel to cassette/ 1.2.1.2 Scapular Y-View
image detector. This view is used to show the relationship of the
–– Usually performed with the arm in a neutral humeral head to the glenoid and also show the
position. The same view with the arm in inter- subacromial space.
nal rotation is used to reveal a Hill-Sachs
deformity while in external rotation it can Technique (Fig. 1.2a)
show the greater tubercle in profile. Patient Position:
–– Standing or lying prone.
Radiographic Beam: –– Body is positioned in an approximate 45–60°
–– Directed in a true anteroposterior plane rela- anterior oblique position with the shoulder to
tive to the body. The scapula is in a coronal be examined in contact with cassette/image
oblique plane (tilted about 40° anteriorly). detector.
The beam is centered medial to the glenohu- –– Arm in neutral rotation.
meral joint.
Radiographic Beam:
Image Analysis and Clinical Benefit –– Directed along the plane of the scapula (true
On this image, one can see the glenohumeral lateral of scapula).
joint, acromioclavicular joint, lateral clavicle,
1 Current Protocols for Radiographic and CT Evaluation of the Shoulder 5
a b c
d e f
g h i
j k l
Fig. 1.1 Radiographic positioning for anteroposterior tion showing the greater tuberosity (*) and (f) internal
(AP) shoulder radiograph in (a) neutral, (b) external rota- rotation position showing the lesser tuberosity (*).
tion, and (c) internal rotation positions. (d–f) Anteroposterior radiographs of the shoulder showing a (g)
Anteroposterior radiographs of the shoulder taken in the proximal humeral fracture (arrow), (h) scapular blade
(a) neutral position showing the glenohumeral joint with fracture (arrow), (i) distal clavicular fracture (arrow), (j)
overlap between the humeral head and the glenoid rim, a anterior shoulder dislocation (arrow), (k) a posterior
smooth scapulohumeral arch (red curve), and the acro- shoulder dislocation, and (l) supraspinatus tendon calcifi-
mioclavicular joint (arrow). The normal acromiohumeral cation (arrows)
internal (>7 mm) is also shown; (b) external rotation posi-
Image Analysis and Clinical Benefit 1.2.1.3 Axillary View

On this image, you can appreciate that the scapu- This view provides a “top-down” view of the
lar body is seen in tangent with the glenoid fossa shoulder joint. It is a very useful view though it
seen en face as a Y-shaped intersection of the may be difficult to obtain in patients with severe
scapular body, acromion process, and coracoid shoulder pain following trauma, in children, or in
process (Fig. 1.2b). The humeral head is centered uncooperative patients.
over the glenoid fossa. The scapular Y-view is
good for determining whether a shoulder disloca- Technique (Fig. 1.3a, b)
tion is anteriorly or posteriorly located as well as Many variations of the axillary view exist. The
revealing fractures of the coracoid process, scap- most commonly used in the outpatient setting is
ula, acromion process, and proximal humeral as follows:
shaft (Fig. 1.2b, d). This view is preferable to the
axillary view when the patient has limited shoul- Patient Position:
der abduction [2]. –– Erect.
a b c
Fig. 1.2 (a) Radiographic positioning for scapular (S). (b). Note how the humeral head is centrically located
Y-view. (b) Normal scapular Y-view showing coracoid over the glenoid. (c) Scapular Y-view showing anterior
process (Cp), acromial process (Ac), and blade of scapula dislocation of humeral head
a b
Fig. 1.3 (a) Radiographic positioning for axillary view. (b) Normal axillary view showing coracoid process (Cp),
acromion (Ac), glenoid (G), and glenohumeral joint (*) which is almost but not quite in profile
Radiographic Beam: (c) Radiographic beam angled 25° upwards

–– Patient leans laterally with arm abducted over and anteriorly centered at glenohumeral
the cassette/image detector which is centered joint.
under axilla. Beam is angled 5–15° (towards
the elbow) centered at the shoulder joint. 1.2.1.4 Acromioclavicular (AC)
Joint View
Image Analysis and Clinical Benefit
This image provides a superior-inferior tangen- The oblique orientation of the acromioclavicular
tial view of glenohumeral joint. The humeral joints is such that either each joint can be radio-
head to glenoid relationship can easily be ascer- graphed in isolation or both joints can be radio-
tained. This view can also assess fractures of the graphed in unison allowing ready side-to-side
anterior glenoid rim and Hill-Sachs deformities comparison. A weight-bearing (stress) view is
as well as fractures of the coracoid process and sometimes performed to accentuate AC joint cap-
subscapularis calcific tendinitis. Glenoid version sular laxity or mild subluxation, and to differenti-
is not accurately assessed on axillary views when ate Rockwood classification of type II and III
compared to CT [3]. injuries.
In the acute trauma setting, one of the three
modified axillary views can be used if the patient Technique (Fig. 1.4a, b)
is unable to abduct the shoulder. All of these Patient Position and Beam:
views can all be taken with the patient’s arm in a –– Single side: AP view with beam directed at the
sling, i.e., there is no need to abduct the arm, and coracoid process.
are very useful at evaluating glenohumeral –– Both AC joints: AP view with beam directed
alignment. at the sternal notch and coned to pass
through both acromioclavicular joints
1. Velpeau view [4]: (Fig. 1.4a).
(a) Patient leans 30° backwards (either sitting – – Weight-bearing AP view (Fig. 1.4b): As
or standing) over horizontally placed cas- per AP view of both AC joints except that
sette/image detector. the patient holds a 5 kg weight in both
(b) Radiographic beam angled vertically hands.
downwards through shoulder joint from
above. Image Analysis and Clinical Benefit
2. Wallace view [5]: This view is primarily used to evaluate AC joint
(a) Upright sitting position. subluxation (Fig. 1.4d, e). One can see both AC
(b) Cassette/image detector placed horizon- joints in profile. The normal width of the AC
tally on table behind humerus in contact joint varies widely and can be up to 7 mm in
with arm. normal subjects [7] with a normal coracoclavic-
(c) Patient rotated 30° so that scapula is par- ular (CC) distance of 11–13 mm [8]. AC joint
allel to the edge of image detector. dislocation is suspected when radiographic
(d) Radiographic beam angled downwards measurements of the AC joint is >7 mm or cora-
and posteriorly 30° from vertical, cen- coclavicular distance is >13 mm [9, 10]. In
tered at glenohumeral joint. addition, to the width of the AC joint, one must
3. Takahashi view [6]: also ensure that the inferior cortices of the clav-
(a) Upright sitting position. icle and the acromion are aligned with each
(b) Cassette/image detector placed on supero- other. AC joint injuries are commonly radio-
anterior aspect of shoulder, angled 25° graphically graded using the Rockwood classifi-
anteroinferiorly. cation (Table 1.1).
a b c
d e
Fig. 1.4 (a) Radiographic positioning for acromiocla- mioclavicular joint space (→, up to 7 mm) and normal
vicular joint radiography: (a) non-weight bearing and (b) coracoclavicular distance (↔, 11-13 mm) are shown.
weight bearing. (c) Normal large-field-of-view image of (d,e). (d) Frontal AC view showing Rockwood grade III
both acromioclavicular joints with weight bearing show- ACJ injury (arrow). (e) Frontal AC view showing distal
ing coracoid process (Cp), acromion (Ac), and clavicle clavicular fracture (arrow) with no acromioclavicular
(Cl) on the right side. On the left side, the normal acro- joint disruption
Table 1.1 Rockwood classification of ACJ injuries [11]

Type Pathology Radiographic findings
I AC ligament partial tear and CC ligament intact Normal
II Complete tear AC ligament with partial tear CC ligament <25% Superior elevation of distal clavicle
III Complete tear of both AC and CC ligaments 25–100% Elevation of distal clavicle
IV Type III + posterior displacement of clavicle (through Posterior dislocation of clavicle behind
trapezius muscle) acromion (best seen on axillary view)
Anterior dislocation of sternoclavicular joint can also occur
V Type III injury + disruption of deltoid and lateral trapezius >100% Elevation of distal clavicle. CC
muscle insertion as well as deltotrapezial fascia distance increased by 100–300%
VI Distal clavicle is displaced inferior to the acromion or Distal end of clavicle located inferior to
coracoid process acromion or coracoid
AC Acromioclavicular, CC coracoclavicular
1.2.2 Specialized Radiographic Image Analysis and Clinical Benefit

Views of the Shoulder The Bernageau view provides a true tangential
view of the anterior rim of the glenoid (Fig. 1.5b).
1.2.2.1 Bernageau View It is useful for assessing glenoid bone loss or frac-
tures of the anterior rim of the glenoid in patients
Technique (Fig. 1.5a) with anterior dislocation. The Bernageau profile
Patient Position: view is a valid and reliable method for quantifying
–– Standing upright. glenoid bone loss revealing glenoid bone loss with
–– Anterior oblique position with arm a sensitivity and specificity of >90% [12]. It can be
abducted at 135° so that the elbow is above used as an alternative to MR or CT assessment
the head. [13]. Bilateral examination for side-to-side com-
parison may help in assessing subtle change [12].
Radiographic Beam:
–– Directed to the posterior aspect of the 1.2.2.2 Stryker Notch View
shoulder.
– – 30 degrees caudal tilt of radiographic Technique (Fig. 1.6a)
beam Patient Position:
–– Optimal angulation of the beam and rotation –– Supine or standing position.
of the patient can be obtained under fluoro- –– Arm extended overhead, elbow flexed, and
scopic guide. palm placed on the back of head.
a b
Fig. 1.5 (a) Radiographic positioning for Bernageau view. (b) Bernageau view showing normal anterior glenoid rim
(arrow)
a b
Fig. 1.6 (a) Radiographic positioning for Stryker notch strated. Ac: Acromion; Cl: clavicle; Cp: coracoid
view. (b) Stryker notch view showing how the posterolat- (radiograph courtesy of Dr. Bill Morrison)
eral aspect (arrow) of the humeral head is well demon-
Radiographic Beam: 1.2.2.3 West Point view

–– Directed to the coracoid process, 10°
cephalad. Technique (Fig. 1.7a)
Patient Position:
Image Analysis and Clinical Benefit –– Prone.
One can appreciate how well the Stryker notch –– Arm abducted to 90° with forearm hanging
view demonstrates the posterolateral aspect of over the edge of the examination table.
the proximal aspect of the humeral head
(Fig. 1.6b). As such, this view is mainly used to Radiographic Beam:
reveal Hill-Sachs deformity which it can detect –– Cassette/image detector placed against the top
with a sensitivity of >90% [1]. A Hill-Sachs of shoulder, perpendicular to the table.
deformity is a compression fracture of the –– Beam centered at axilla, with 25° downward
humeral head caused by impaction of the humeral angulation from horizontal and 25° medial
head against the anterior or anteroinferior aspect angulation.
of the glenoid after anterior dislocation. Hill-
Sachs deformity is seen as a diffuse flattening or Image Analysis and Clinical Benefit
a more angulated depression at the posterolateral The West Point view is a modified axillary pro-
aspect of the humeral head. Large or angulated jection that similar to the Bernageau view dem-
Hill-Sachs deformities can engage with the gle- onstrates fractures or bone loss of the anterior
noid rim during external rotation precipitating glenoid rim (Fig. 1.7b) [14]. While on an axillary
anterior dislocation. Comparison with the normal view the lateral clavicle overlaps the anterior rim
opposite side can be helpful in qualifying the size of the glenoid, this is not a feature of the West
of defect present. Point view. The West Point view can identify
a b
Fig. 1.7 (a) Radiographic positioning for West Point (open arrow). A medium-sized Hill-Sachs deformity is
view. (b) West Point view is used to evaluate the anterior also shown (arrow) (radiograph courtesy of Dr. Bill
glenoid rim for fracture and anterior glenoid bone loss Morrison)
a b
Fig. 1.8 (a) Radiographic positioning for Grashey view (b) The Grashey view provides a tangential view of the gleno-
humeral joint (radiograph courtesy of Dr. Bill Morrison)
anterior glenoid rim fractures with 70% sensitiv- Radiographic Beam:

ity [14, 15]. –– Directed perpendicular to cassette/image
detector and provide tangential view of gleno-
1.2.2.4 Grashey View humeral joint.
Technique (Fig. 1.8a) Image Interpretation and Clinical Benefit

Patient Position: The Grashey view is a posterior oblique view
–– Patient’s body angled 35°–45° with the scap- with the glenoid articular surface in profile, i.e., it
ula against and parallel to the cassette/image is a true AP view of the glenohumeral joint space
detector. and is used to evaluate widening or narrowing of
this joint.
Other specialized view: 1.3.1 CT Technique (64-Slice

• Garth view: Radiographic beam is angled
Multidetector CT)
caudally 45° from that used to obtain the stan-
Irrespective of the clinical indication for shoulder
dard anteroposterior view of the shoulder
CT, the scanning protocol used is identical for all
joint. The beam is then tangential to the
patients.
anteroinferior glenoid rim. The Garth view is
used to detect Bankart fractures and Hill-
• Supine position.
Sachs deformity [16].
• Shoulder close to gantry center.
• Upper arm close to body.
1.3 Computed Tomography
Parameters:
of the Shoulder
• Kv120kV.
• Effective mA: 300–400 mA.
CT of the shoulder is mainly used to:
• Detector collimation: 64 × 0.625 mm.
• Scan plane extends from the top of the acro-
(a) Diagnose and classify acute fracture
mion to below the glenoid.
(Fig. 1.9a, b).
(b) Quantify glenoid bone loss (Fig. 1.10a–d).
(c) Assess severe glenohumeral arthritis preop-
1.3.2 pecific Clinical Indications
S
eratively (Fig. 1.11a, b).
for Shoulder CT
(d) Assess fracture healing.
(e) Assess shoulder prostheses and internal fixa-
CT improves classification of proximal humeral
tion (Fig. 1.12).
[17] and glenoid/scapular neck [18, 19] fractures
a b
Fig. 1.9 Comminuted fracture of proximal humerus (arrows) shown on coronal (a) and three-dimensional (b)
reconstruction
a b
c d
Fig. 1.10 CT of the normal (a, b) shoulder showing a the glenoid. The glenoid width is reduced to 24.3 mm. The
normal curved anterior glenoid rim (arrows) with a gle- glenoid bone loss is therefore 26.1–24.3 mm = 1.8 mm or
noid width of 26.1 mm. On the contralateral shoulder (c, alternatively 1.8/26.1 x 100 = 6.9%. This is considered to
d) with recurrent dislocation, there is loss of the normal be mild glenoid bone loss
curvature with an anterior straight line (14 mm long) to
compared to radiographs allowing more accurate osteoarthritic shoulder, as well as estimation of

decisions to be made regarding the need for and premorbid glenoid bone stock and humeral head
form of operative treatment and fixation [20]. 3D size (Youdarian AR 2013). Not recognizing gle-
CT reconstruction improves proximal humeral noid retroversion can lead to a retroverted pros-
fracture classification (Neer or ATAO classifica- thesis and an increased risk of posterior instability.
tion) compared to 2D reconstructions [17, 21]. Prior to CT, glenoid version was measured on
CT examination is now almost a routine pre- axillary view radiographs. Glenoid version is the
operative investigation for patients with severe angle between (a) a line drawn from the medial
glenohumeral osteoarthritis being considered for border of the scapula to the center of the glenoid
total shoulder arthroplasty (TSA) [22]. CT and (b) a line perpendicular to the face of the gle-
enables preoperative determination of glenoid noid on an axial CT image at or just below the tip
retroversion, which is a common feature of the of the coracoid process (Fig. 1.12b). The normal
a b c
Fig. 1.11 (a) Axial CT of severe glenohumeral osteoar- B). Draw a line along the face of the glenoid (line C).
thritis. (b) The same image as A with measurement of gle- Glenoid version is the angle between lines B and C. In this
noid version. To measure glenoid version draw a line from case, glenoid retroversion is −2° which is normal. (c) In
the medial border of the scapula to the center of the gle- this other case, glenoid version is −35° which is abnor-
noid (line A). Draw a line perpendicular to this line (line mal. Normal glenoid version is from +5° to −15°
a b c
Fig. 1.12 (a) Radiograph of shoulder showing fracture comminuted proximal humeral fracture in another patient
proximal humerus postfixation. (b) 2D coronal recon- with volume rendering and windowing designed to
struction of same patient as previous image showing increase bone transparency allowing clearer view of
incomplete fracture healing with screw tip protruding metallic fixation devices (arrow). There are also some
across the articular surface. (c) 3D CT reconstruction of antibiotic beads in situ (open arrow)
glenoid version is from 5° anteversion to 15° Glenoid component failure is the most com-
retroversion. mon complication of total shoulder arthroplasty.
Restoration of glenoid version to neutral is CT is more sensitive than radiography at reveal-
one’s aim of TSA while premorbid head size ing periprosthetic lucency, which is the cardinal
estimation allows selection of the appropriate sign of prosthetic loosening [26]. CT scanning in
anatomically sized prosthetic head [23]. CT is the lateral decubitus position with maximum for-
also helpful in evaluating bone morphology, pos- ward flexion aligns the glenoid with the CT scan
terior or superior humeral head subluxation, sub- plane and thus helps to minimize metallic artifact
chondral bony resorption, and bone density—all around the glenoid prosthesis [26].
of which help guide prosthesis shape selection Assessment of glenoid bone loss (GBL) is a
and positioning as well as operative technique common indication for CT examination though
[24, 25]. this is likely to be increasingly undertaken solely
Fig. 1.14 2D double-oblique reconstruction en face to

Fig. 1.13 3D CT reconstruction of shoulder in patient the glenoid. This shows severe glenoid bone loss with a
with anterior dislocation showing large fracture (arrow) of concave rather than convex anterior curvature to the gle-
anterior glenoid rim. 3D allows very good perception of noid (arrows). An anterior concavity is normally associ-
fracture fragments. The humeral head has been electroni- ated with severe (>20%) anterior glenoid bone loss
cally disarticulated to allow an unobstructed clear en face
view of the glenoid
by MR examination [27]. The following are 12 9. Critical GBL is >15%. At this level, the fre-
basic concepts regarding CT assessment of GBL quency of anterior dislocations seems to
[28–30]: increase.
10. A Hill-Sachs deformity ± some degree of
1. GBL after shoulder dislocation is very com- GBL seems to be present in all patients with
mon (>80%). documented anterior shoulder dislocation.
2. Most (>90%) GBL is not associated with a 11. CT has good agreement (r = 0.79) with
glenoid rim fracture (Fig. 1.13). shoulder arthroscopy regarding the severity
3. GBL first affects the anterior rather than the of glenoid bone loss. That said, arthroscopy
anteroinferior aspect of the glenoid. is not the perfect gold standard.
4. The earliest sign of GBL is an anterior 12. GBL can be assessed by radiography, MR, or
straight line to the anterior glenoid rim. If an CT. Of these approaches, CT with compari-
anterior straight line is not present, i.e., if the son of the opposite side seems to be the most
anterior glenoid rim is curved, then there is accurate while MR seems to be the most
no GBL present. practical.
5. Excellent side-to-side symmetry in glenoid
shape and size exists such that the contralat-
eral shoulder can be used as a template for 1.3.3 ow to Quantify GBL Using CT
H
initial glenoid size. (Fig. 1.10a–d)
6. Mild GBL is <10% bone loss, moderate
10–20%, and severe >20% bone loss. The best CT method is to compare both shoul-
7. The most severe GBL is 33%. ders, i.e., the dislocating side with the non-
8. With severe GBL, the anterior glenoid rim dislocating side. For CT of a single shoulder, the
becomes concave (Fig. 1.14), rather than contralateral shoulder will necessarily be
straight as seen in mild-to-moderate degrees included in the scan plane (i.e., irradiated) so it
of GBL. is best to employ a large field of view and use
the information from the contralateral normal

shoulder to your advantage. A double-oblique
reconstruction technique is used to obtain an en
face view of each glenoid articular surface. On
this en face view, first note whether there is an
anterior straight line present. If there is no ante-
rior straight line, then there is no glenoid bone
loss and it can be reported as such without any
need to do additional measurements. If there is
an anterior straight line present, the amount of
glenoid bone loss should be quantified. This is
done by first drawing a line along the long axis
of the glenoid (Saller line). Glenoid width is
then measured at right angles to the long axis of
the glenoid at the midportion of the rounded
inferior two-thirds of the glenoid. Absolute (in Fig. 1.15 Axial CT of the shoulder through the proximal
mm) and percentage (%) glenoid bone loss is aspect of the humeral head. There is a large angulated
Hill-Sachs deformity (arrow) at the posterosuperior aspect
then calculated as the difference between the of the humeral head. Such large, angulated deformities
width of the glenoid on the dislocating side may “engage” with the glenoid rim during external rota-
compared to that of the contralateral normal gle- tion precipitating anterior dislocation
noid. This method is applicable in all cases
except when there is bilateral dislocation with
bilateral GBL.
If there has been bilateral dislocation with
bilateral GBL or if only a single shoulder has
undergone CT examination, an alternative
method is to use the best-fit circle method.
This involves applying the smallest possible
best-fit circle to the rounded inferior two-
thirds of the glenoid. The margins of the circle
should just contact the cortex of the glenoid
except for along the anterior glenoid rim. The
limitation of this technique is that the inferior
two-thirds of the glenoid does not always have
a completely circular shape. A noncircular
configuration to the glenoid before bone loss
will not be captured with the best-fit circle
Fig. 1.16 Axial CT arthrogram in patient following ante-
technique.
rior dislocation showing absence of the anterior labrum
Hill-Sachs lesions are seen on CT in over 80% (arrow) which had retracted inferiorly
of patients with anterior dislocation [30] being,
as expected, more frequent and larger in recurrent 1.3.4 CT Arthrography
dislocation. Large or angulated Hill-Sachs defor-
mities (known as “engaging” Hill-Sachs defor- CT arthrography is not as commonly performed
mities) are a risk factor for recurrent dislocation nowadays with the more widespread availability
(Fig. 1.15). CT will not demonstrate purely carti- of MRI. CT arthrography is however a valid
laginous Hill-Sachs lesions though these are alternative for shoulder imaging of patients with
much less common and of little clinical signifi- contraindications to MRI or after failed MRI [32]
cance [31]. (Fig. 1.16). CT arthrography is accurate for
assessment of most intra-articular shoulder For glenohumeral cartilage defects, CTA has
abnormalities and may become the imaging test moderate diagnostic performance though it is
of choice for evaluation of the postoperative more accurate than MR arthrography in this
shoulder [32]. respect with improved inter-observer agreement
(κ = 0.63) compared to MRA (κ = 0.54) for detec-
1.3.4.1 Technique tion of modified Outerbridge grade ≥2 and grade
For CT arthrography, intra-articular contrast 4 chondral defects [40]. Multidetector CT
injection is performed under either ultrasound or arthrography also shows high accuracy and good
fluoroscopic guidance, most commonly using the inter-observer reliability for diagnosis of superior
anterior approach aiming at the rotator cuff inter- labral anterior to posterior (SLAP) tears [41].
val. The patient is positioned supine with the External rotation and active supination during CT
hand fully supinated to achieve external rotation arthrography seem to improve the SLAP tear
of the humeral head. A standard spinal needle detection compared with neutral-position CT
(20–22 gauge) containing 12 ml of a solution of arthrography [37]. The mean gap width of a
5 ml normal saline, 10 ml Omnipaque 300, and SLAP tear was greater during CT arthrography
5 ml 1% lidocaine is used. The needle tip is with external rotation and active supination
advanced to the upper third of medial articular (ERAS) (3.98 mm ± 2.48 sd) compared to neutral
surface of humeral head prior to injection of this CT arthrography (1.61 mm ± 1.11), while the
contrast medium solution into the glenohumeral mean gap depth did not alter significantly [37].
joint. Local anesthetic (2% mepivacaine) does Multidetector CT arthrography also shows
not seem to reduce post-arthrography pain [33]. high accuracy for detection of rotator cuff tendon
Lowering tube voltage from 140 kVp to 120 kVp tears. Abduction and external rotation (ABER)
reduces the radiation dose by as much as 33% positioning before CT seems to improve the
without significant loss of image quality [34]. delineation of partial rotator cuff tendon tears
One can also consider using a posterior allowing demonstration of a higher number of
approach to guide intra-articular injection as this tendon tears than CT in which no ABER posi-
seems to be easier with less risk of extravasation tioning was performed beforehand [36].
than the rotator cuff interval approach [35]. Also, Compared to arthroscopy, both CT arthrography
abduction and external rotation (ABER) posi- and MR arthrography perform poorly in the
tioning before CT seems to improve dispersion of detection of biceps tendon pathology (tendinosis,
intra-articular contrast medium and increase the tendon subluxation, partial and complete tendon
sensitivity to detection of rotator cuff tears [36] tears) [42]. CT arthrography was found to be
while external rotation and active supination per- more sensitive and specific than MRI in identify-
formed during CT arthrography seems to improve ing biceps tendinosis [43]. Compared to arthros-
detection of SLAP tears [37]. copy however, both tests were not perfect. CT
arthrography had a sensitivity of 71%, a specific-
ity of 100%, positive predictive value of 100%,
1.3.5 linical Uses of CT
C and negative predictive value of 68% for reveal-
Arthrography ing biceps tendinosis [43].
Following total shoulder arthroplasty, CT
MDCT arthrography is a valid alternative for arthrography has been used to assess prosthetic
shoulder imaging of patients in whom MRI is loosening with the cardinal sign being intra-
contraindicated or after failed MRI. MDCT articular contrast medium leaking deep to the
arthrography has comparable accuracy to MRI polyethylene component. CT arthrography is,
for identifying chondral, fibrocartilaginous, and however, only moderately accurate at determin-
rotator cuff tears [32, 38, 39] and may even be the ing glenoid component loosening with a sensitiv-
imaging test of choice for evaluating the postop- ity of 70%, a specificity of 75%, a positive
erative shoulder [32]. predictive of 87.5%, and a negative predictive
value of 50.0% [44]. More studies and improved of CT examinations providing added relevant
techniques to increase CT accuracy in this respect information when CT is used to examine com-
are required. plex fractures around the shoulder. Early studies
Following arthroscopic superior labrum ante- show poor correlation between DXA and DECT
rior to posterior (SLAP) repair, superior labral BMD measurements of the lumbar spine which
clefts, defined by leakage of contrast medium is not surprising since the former is measuring
between the superior labrum and the anchor site, integral BMD and the latter trabecular BMD
are seen in almost 50% of patients on CT arthrog- [50]. DECT seems to provide a better estimation
raphy and do not seem to correlate with clinical of bone strength correlating better the pullout
outcome [45]. strength used to extract pedicular screws than
DXA. The most widely used application of
DECT to date is its noninvasive and highly spe-
1.3.6 Dual-Energy CT (DECT) cific ability for confirming the presence of and
quantifying the amount of monosodium urate
DECT simultaneously irradiates the area under deposits in patients with gout [46]. In a study of
investigation with two X-ray beams of different six cadaveric internally fixed humeri, both
KVp—typically 80 KVp and 120 KVp. This mono-energetic DECT and single-energy CT
enables it to provide added information on the using an iterative- frequency split-normalized
chemical composition of the tissues under inter- metal artifact reduction algorithm yielded
rogation, based on the differential X-ray attenua- improved image quality and a reduction of metal
tion. It can be used to assess bone marrow edema, artifact when compared to filtered back projec-
bone mineral density, tendons, and ligaments and tion on singe-energy CT [51]. Screw-tip posi-
crystal deposition [46]. Many of these application could be most confidently assessed using
tions are currently being researched. Using vir- DECT [50].
tual non-calcium images, generated by
dual-energy subtraction of calcium, good inter-
rater reliability (k = 0.85) in the detection of trau- 1.3.7 Iterative CT
matic bone marrow edema in both other than
those at the shoulder by dual-energy CT has been One of the latest developments in CT technology
shown [47]. The CT value of traumatized proxi- is “ultralow-dose CT” (256 ICT Brilliance)
mal tibial bone marrow was −51.3 ± 30.2 HU which employs a combination of vacuum slip-
while that of normal bone marrow was ring technology and an iterative model recon-
−104.7 ± 17.5 HU (p < 0.0001) [47]. DECT can struction (IMR). This helps to reduce noise
use monoenergetic techniques to significantly (which will improve image quality), reduce radi-
reduce metallic beam hardening artifact [48]. ation dose to only about 1/6 standard CT dose,
This is clearly beneficial to the assessment of the and reduce metallic artifact. These advantages
shoulder following treatment with internal fixa- have been shown in the abdomen, coronary arter-
tion or a prosthesis. ies, and thorax [52–54] though the shoulder
Phantomless DECT has the potential to pro- region has not been specifically evaluated.
vide a more accurate estimation of bone mineral Clearly it would be beneficial to shoulder imag-
density (BMD) than DXA or multidetector CT ing to reduce dose to the breast area and improve
(MDCT) and has the added potential of provid- image resolution following internal fixation [52–
ing a measure of marrow constituents as well as 54]. To reduce metallic artifact with iterative CT,
being able to provide marrow-free quantifica- imaging with a slightly higher KVp (140KVP)
tion of trabecular BMD. A deformable template than usual (120KVp) is recommended. The
mesh has been used to define trabecular bone on acquired data is then subjected to an automatic
DECT [49]. Such information on bone quality is post-processing algorithm which can yield sig-
likely to become an increasingly utilized aspect nificant improvement in image quality
a b
Fig. 1.17 (a) Original image showing streak (arrow) and shows significant improvement in diagnostic quality
darkening (open arrow) artifacts from hip prosthesis. (b) (image courtesy of Philips Health Systems)
Corrected image following metallic artifact reduction
a b
Fig. 1.18 (a) Original image showing noise (arrows) due allowing improved visibility of the humeral head prosthe-
to metal artifact from humeral head prosthesis. (b) sis (open arrow) (image courtesy of Philips Health
Corrected image showing significantly reduced noise fol- Systems)
lowing application of metallic artifact reduction software
p articularly with large metallic implants such as 2. Rubin SA, Gray RL, Green WR. The scapular Y: a
hip or shoulder prostheses (Figs. 1.17 and 1.18). diagnostic aid in shoulder trauma [technical note].
Radiology. 1974;110:725–6.
3. Nyffeler RW, Jost B, Pfirrmann CW, et al.
Acknowledgement We wish to thank Ms. Judy Wong Measurement of glenoid version: conventional
Yee Ha, radiographer, for her help and advice with select- radiographs versus computed tomography scans. J
ing radiographs for this chapter. Shoulder Elbow Surg. 2003;12(5):493–6.
4. Bloom MH, Obata WG. 1967 Diagnosis of poste-
rior dislocation of the shoulder with use of Velpeau
axillary and angle-up roentgenographic views. J Bone
References Joint Surg Am. 1967;49(5):943–9.
5. Wallace WA, Hellier M. Improving radiographs of the
1. Pavlov H, Warren RF, Weiss CB, et al. The roentgeno- injured shoulder. Radiography. 1983;49:229–33.
graphic evaluation of anterior shoulder instability. 6. Takahashi K, Kato K, Ishida H, Sai S, Nakazawa
Clin Orthop Relat Res. 1985;194:153–8. Y. Study of a new axial projection of shoulder
joint without abduction of upper extremity. Nihon and three-dimensional CT. J Bone Joint Surg Am.
Hoshasen Gijutsu Gakkai Zasshi. 2011;67(2):137–44. 2013;95(17):1600–4.
Japanese 22. Walch G, Mesiha M, Boileau P, Edwards TB, Lévigne
7. Petersson CJ, Redlund-Johnell I. Radiographic joint C, Moineau G, Young A. Three-dimensional assess-
space in normal acromioclavicular joints. Acta Orthop ment of the dimensions of the osteoarthritic glenoid.
Scand. 1983;54(3):431–3. Bone Joint J. 2013;95-B(10):1377–82.
8. Bearden J, Hughston J, Whatley G. Acromioclavicular 23. Youderian AR, Ricchetti ET, Drews M, Iannotti
dislocation: method of treatment. Am J Sports Med. JP. Determination of humeral head size in anatomic
1973;1:5–17. shoulder replacement for glenohumeral osteoarthritis.
9. Mazzocca AD, Arciero RA, Bicos J. Evaluation and J Shoulder Elb Surg. 2014;23(7):955–63.
treatment of acromioclavicular joint injuries. Am J 24. Terrier A, Ston J, Farron A. Importance of a three-
Sports Med. 2007;35(2):316–29. dimensional measure of humeral head subluxation
10. Melenevsky Y, Yablon CM, Ramappa A. Clavicle and in osteoarthritic shoulders. J Shoulder Elb Surg.
acromioclavicular joint injuries: a review of imag- 2015;24(2):295–301.
ing, treatment, and complications. Skelet Radiol. 25. Sharma GB, McMahon PJ, Robertson DD. Structure
2011;40(7):831–42. modeling of the glenoid: Relevance to shoulder
11. Rockwood CA Jr, Williams GR, Young CD. Injuries arthroplasty. J Orthop Res. 2014;32(11):1471–8.
to the acromioclavicular joint. In: Rockwood Jr 26. Gregory T, Hansen U, Khanna M, Mutchler C, Urien
CA, et al., editors. Fractures in adults. Philadelphia: S, Amis AA, Augereau B, Emery R. A CT scan proto-
Lippincott; 1996. p. 1341–431. col for the detection of radiographic loosening of the
12. Edwards TB, Boulahia A, Walch G. Radiographic glenoid component after total shoulder arthroplasty.
analysis of bone defects in chronic anterior shoulder Acta Orthop. 2014;85(1):91–6.
instability. Arthroscopy. 2003;19:732–9. 27. Lee RK, Griffith JF, Tong MM, et al. Glenoid bone
13. Pansard E, Klouche S, Billot N, et al. Reliability and loss: assessment with MR imaging. Radiology.
validity assessment of a glenoid bone loss measure- 2013;267(2):496–502.
ment using the Bernageau profile view in chronic 28. Griffith JF, Antonio GE, Tong CW, et al. Anterior
anterior shoulder instability. J Shoulder Elbow Surg. shoulder dislocation: quantification of glenoid bone
2013;22(9):1193–8. loss with CT. Am J Roentgenol. 2003;180(5):1423–30.
14. Rokous JR, Feagin JA, Abbott HG. Modified axil- 29. Griffith JF, Yung PS, Antonio GE, et al. CT compared
lary roentgenogram, a useful adjunct in the diagnosis with arthroscopy in quantifying glenoid bone loss.
of recurrent instability of the shoulder. Clin Orthop. AJR Am J Roentgenol. 2007;189(6):1490–3.
1972;82:84. 30. Griffith JF, Antonio GE, Yung PS, et al. Prevalence,
15. Itoi E, Lee SB, Amrami KK, et al. Quantitative assess- pattern, and spectrum of glenoid bone loss in anterior
ment of classic anteroinferior bony Bankart lesions by shoulder dislocation: CT analysis of 218 patients. Am
radiography and computed tomography. Am J Sports J Roentgenol. 2008;190(5):1247–54.
Med. 2003;31(1):112–8. 31. Ozaki R, Nakagawa S, Mizuno N, Mae T, Yoneda
16. Garth WP Jr, Slappey CE, Ochs CW. Roentgeno- M. Hill-Sachs lesions in shoulders with traumatic
graphic demonstration of instability of the shoulder: anterior instability: evaluation using computed
the apical oblique projection. A technical note. J Bone tomography with 3-dimensional reconstruction. Am J
Joint Surg. 1984;66A:1450–3. Sports Med. 2014;42(11):2597–605.
17. Berkes MB, Dines JS, Little MT, Garner MR, 32. Fritz J, Fishman EK, Small KM, Winalski CS,
Shifflett GD, Lazaro LE, Wellman DS, Dines DM, Horger MS, Corl F, McFarland E, Carrino JA,
Lorich DG. The impact of three-dimensional CT Fayad LM. MDCT arthrography of the shoulder
imaging on intraobserver and interobserver reliabil- with datasets of isotropic resolution: indications,
ity of proximal humeral fracture classifications and technique, and applications. AJR Am J Roentgenol.
treatment recommendations. J Bone Joint Surg Am. 2012;198(3):635–46.
2014;96(15):1281–6. 33. Choo HJ, Lee SJ, Kim DW, Choi SJ, Lee IS. Intra-
18. Van Oostveen DP, Temmerman OP, Burger BJ, van articular local anesthesia: can it reduce pain related to
Noort A, Robinson M. Glenoid fractures: a review of MR or CT arthrography of the shoulder? AJR Am J
pathology, classification, treatment and results. Acta Roentgenol. 2013;200(4):860–7.
Orthop Belg. 2014;80(1):88–98. 34. Ahn SJ, Hong SH, Chai JW, Choi JY, Yoo HJ, Kim SH,
19. Bartoníček J, Tuček M, Frič V, Obruba P. Fractures of Kang HS. Comparison of image quality of shoulder
the scapular neck: diagnosis, classifications and treat- CT arthrography conducted using 120 kVp and 140
ment. Int Orthop. 2014 Oct;38(10):2163–73. kVp protocols. Korean J Radiol. 2014;15(6):739–45.
20. Brorson S. Fractures of the proximal humerus. Acta 35. Ogul H, Bayraktutan U, Ozgokce M, et al. Ultrasound-
Orthop Suppl. 2013;84(351):1–32. guided shoulder MR arthrography: comparison of
21. Bruinsma WE, Guitton TG, Warner JJ, Ring D, rotator interval and posterior approach. Clin Imaging.
Science of Variation Group. Interobserver reli- 2014;38(1):11–7.
ability of classification and characterization of 36. Cochet H, Couderc S, Pelé E, et al. Rotator cuff
proximal humeral fractures: a comparison of two tears: should abduction and external rotation
(ABER) positioning be performed before image and correlation with clinical outcome. Radiology.
acquisition? A CT arthrography study. Eur Radiol. 2015;1:142431.
2010;20(5):1234–41. 46. Nicolaou S, Liang T, Murphy DT, et al. Dual-energy
37. Choi JY, Kim SH, Yoo HJ, Shin SH, Oh JH, Baek CT: a promising new technique for assessment
GH, Hong SH. Superior labral anterior-to-posterior of the musculoskeletal system. Am J Roentgenol.
lesions: comparison of external rotation and active 2012;199(5 Suppl):S78–86.
supination CT arthrography with neutral CT arthrog- 47. Cao JX, Wang YM, Kong XQ, et al. Good interra-
raphy. Radiology. 2012;263(1):199–205. ter reliability of a new grading system in detecting
38. De Filippo M, Bertellini A, Sverzellati N, Pogliacomi traumatic bone marrow lesions in the knee by dual
F, Costantino C, Vitale M, Zappia M, Corradi D, energy CT virtual non-calcium images. Eur J Radiol.
Garlaschi G, Zompatori M. Multidetector com- 2015;84:1109.
puted tomography arthrography of the shoulder: 48. Coupal TM, Mallinson PI, McLaughlin P, et al.
diagnostic accuracy and indications. Acta Radiol. Peering through the glare: using dual-energy CT to
2008;49(5):540–9. overcome the problem of metal artefacts in bone radi-
39. Lecouvet FE, Simoni P, Koutaïssoff S, Vande Berg ology. Skelet Radiol. 2014;43(5):567–75.
BC, Malghem J, Dubuc JE. Multidetector spiral CT 49. Wichmann JL, Booz C, Wesarg S, et al. Quantitative
arthrography of the shoulder. Clinical applications dual-energy CT for phantomless evaluation of cancel-
and limits, with MR arthrography and arthroscopic lous bone mineral density of the vertebral pedicle:
correlations. Eur J Radiol. 2008;68(1):120–36. correlation with pedicle screw pull-out strength. Eur
40. Omoumi P, Rubini A, Dubuc JE, Vande Berg Radiol. 2015;25(6):1714–20.
BC, Lecouvet FE. Diagnostic performance of 50. Wichmann JL, Booz C, Wesarg S, Kafchitsas K,
CT-arthrography and 1.5T MR-arthrography for the Bauer RW, Kerl JM, Lehnert T, Vogl TJ, Khan
assessment of glenohumeral joint cartilage: a compar- MF. Dual- energy CT-based phantomless in vivo
ative study with arthroscopic correlation. Eur Radiol. three-dimensional bone mineral density assessment
2015;25(4):961–9. of the lumbar spine. Radiology. 2014;271(3):778–84.
41. Kim YJ, Choi JA, Oh JH, Hwang SI, Hong SH, 51. Winklhofer S, Benninger E, Spross C, Morsbach
Kang HS. Superior labral anteroposterior tears: F, Rahm S, Ross S, Jost B, Thali MJ, Stolzmann P,
accuracy and interobserver reliability of multide- Alkadhi H, Guggenberger R. CT metal artefact reduc-
tector CT arthrography for diagnosis. Radiology. tion for internal fixation of the proximal humerus:
2011;260(1):207–15. value of mono-energetic extrapolation from dual-
42. De Maeseneer M, Boulet C, Pouliart N, et al. energy and iterative reconstructions. Clin Radiol.
Assessment of the long head of the biceps ten- 2014;69(5):e199–206.
don of the shoulder with 3T magnetic resonance 52. Khawaja RD, Singh S, Blake M, et al. Ultra-low dose
arthrography and CT arthrography. Eur J Radiol. abdominal MDCT: using a knowledge-based Iterative
2012;81(5):934–9. Model Reconstruction technique for substantial dose
43. Nourissat G, Tribot-Laspiere Q, Aim F, et al. reduction in a prospective clinical study. Eur J Radiol.
Contribution of MRI and CT arthrography to the diag- 2015;84(1):2–10.
nosis of intra-articular tendinopathy of the long head 53. Matsuura N, Urashima M, Fukumoto W, et al.
of the biceps. Orthop Traumatol Surg Res. 2014;100(8 Radiation dose reduction at coronary artery cal-
Suppl):S391–4. cium scoring by using a low tube current technique
44. Mallo GC, Burton L, Coats-Thomas M, Daniels SD, and hybrid iterative reconstruction. J Comput Assist
Sinz NJ, Warner JJ. Assessment of painful total shoul- Tomogr. 2015;39(1):119–24.
der arthroplasty using computed tomography arthrog- 54. Khawaja RD, Singh S, Madan R, et al. Ultra low-
raphy. J Shoulder Elb Surg. 2015;31:S1058–2746. dose chest CT using filtered back projection: com-
45. Choi BH, Kim NR, Moon SG, Park JY, Choi parison of 80-, 100- and 120 kVp protocols in
JW. Superior labral cleft after superior labral anterior- a prospective randomized study. Eur J Radiol.
to-
posterior tear repair: CT arthrographic features 2014;83(10):1934–44.
Technical Update in Conventional
and Arthrographic MRI 2
of the Shoulder
Seema Meraj and Jenny T. Bencardino
Magnetic resonance (MR) is the imaging modality

of choice for the evaluation of the shoulder, offer-
ing superior soft-tissue contrast while acquiring
images in multiple planes. Various factors affect
shoulder MR acquisition including the strength of
the magnetic field, position of the patient, selec-
tion of imaging planes, and use of contrast.
2.1 Conventional MR Protocol

Fig. 2.1 Patient positioning for conventional shoulder
MR imaging of the shoulder is performed with the MR. The patient is supine on the MRI table with the
patient supine and the arm parallel to the long axis affected arm close to and parallel to the body (yellow line)
and the thumb pointed up (red circle) so that the shoulder
of the body, with the thumb facing up (Fig. 2.1). The is held in slight external rotation within the shoulder coil.
upper extremity is held as close as possible to the Note that the arm is propped with sandbags (blue circle) to
body so that it is nearest to the center of the magnet, ensure parallel positioning
with the shoulder held in partial external rotation
and placed in a dedicated shoulder coil. To ensure dancy and to enable the discrete evaluation of the
parallel positioning relative to the body, the patient’s supraspinatus and infraspinatus tendons, which
arm can be supported by weights and/or sandbags tend to overlap in this position [1]. Conversely,
placed under the elbow. The shoulder is not held in exaggerated external rotation can result in false-
internal rotation to avoid anterior capsular redun- positive tendon tears because potential fluid signal
within the biceps tendon sheath may blend with the
anterior lateral supraspinatus tendon, mimicking
S. Meraj (*) tear [1]. A wide strap is then wrapped around the
Zwanger-Pesiri Radiology, Lindenhurst, NY, USA patient’s shoulder and secured to the table to limit
e-mail: smeraj@zprad.com respiratory motion-related artifact.
J. T. Bencardino
Department of Radiology, New York University
2.1.1 Technique and Protocol
Penn Medicine, Department of Radiology, Perelman
School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA 3.0T MR imaging is preferred in the evaluation
e-mail: jenny.bencardino@nyumc.org of the shoulder because of the greater signal-to-

24 S. Meraj and J. T. Bencardino
noise ratio (SNR) and contrast-to-noise ratio pressed (Table 2.1). It is important for the
(CNR) offered by higher field strengths due to sagittal-oblique images to be obtained in T1 or pro-
faster acquisition time and thinner slice selec- ton density/T2 with and without fat suppression in
tion. Studies have shown that imaging the shoul- order to properly assess the osseous structures as
der at higher field strengths allows for more well as fat, particularly when assessing for muscle
accurate interpretation and can also affect man- atrophy in the setting of chronic rotator cuff tear or
agement [2]. denervation-related muscle injury (Fig. 2.3).
Once the localizer images are obtained, stan-
dard conventional MR imaging of the shoulder is
acquired in three orthogonal planes: axial, coronal- 2.1.2 Accuracy
oblique, and sagittal-oblique (Fig. 2.2). Axial
sequences are imaged from the superior margin of Shellock and colleagues found that noncontrast
the acromion through the inferior aspect of the gle- MRI has a sensitivity of 89% and a specificity of
noid. The coronal-oblique images are obtained 100% in the detection of rotator cuff tears, miss-
from the infraspinatus to the subscapularis mus- ing only partial tears, on a 0.2T extremity MRI
cles, parallel to the course of the supraspinatus ten- system [3]. Noncontrast MRI is also accurate in
don on the axial images, such that the muscles of the evaluation of cartilage lesions with a sensitiv-
the rotator cuff can be seen in continuity. Finally, ity and specificity of up to 53% and 93% for gle-
the sagittal-oblique images are obtained parallel to noid lesions, and 32% and 80% for humeral
the glenoid surface, perpendicular to the coronal- lesions, respectively, on 1.5T and 3T MRI scan-
oblique images from the level of the scapular neck ners [4, 5].
to the greater tuberosity. Conventional noncontrast MR examinations
At our institution, five sequences are typically of the shoulder are sensitive and accurate in the
obtained: an axial proton density fat suppressed, assessment of anterior labrum tears and less
coronal oblique proton density and T2-fat sup- sensitive for superior labral tears [6, 7]. At 3.0T,
pressed, and sagittal oblique T1 and T2 fat sup- Magee and Williams found a sensitivity and
a b c
Fig. 2.2 Imaging planes. The imaging planes for conventional noncontrast imaging in the (a) axial, (b) coronal-
oblique, and (c) sagittal-oblique planes
Table 2.1 Protocol for conventional noncontrast 3.0T MRI of the shoulder
Sequence TR (ms) TE (ms) Slice thickness (mm) FOV (mm) Matrix (%)
Coronal PD 4500 32 2.0 140 × 140 320 × 75
Coronal T2 FS 3500 72 3.0 140 × 140 256 × 151
Sagittal T1 600 11 2.5 140 × 140 320 × 90
Sagittal T2 FS 5000 62 2.5 140 × 140 320 × 75
Axial PD 3030 33 2.0 140 × 140 256 × 100
PD proton density, FS fat suppressed
2 Technical Update in Conventional and Arthrographic MRI of the Shoulder 25
a b
Fig. 2.3 Rotator cuff denervation. Sagittal oblique (a) tus and infraspinatus muscles (circled) as a result of
T2-weighted fat-suppressed and (b) T1-weighted images suprascapular nerve impingement by a paralabral cyst in
of the shoulder demonstrating faint denervation edema the suprascapular notch (not visualized)
-like changes and mild fatty infiltration of the supraspina-
specificity of 90% and 100%, respectively, in supine (Fig. 2.4). The shoulder coil is placed
the detection of SLAP tears on conventional anteriorly over the shoulder and scout images
MRI, 89% and 100%, respectively, in the detec- are obtained in a plane parallel to the long axis
tion of anterior labral tears, and 86% and 100%, of the humerus, perpendicular to the glenohu-
respectively, in the detection of posterior labral meral articular surface. The images obtained are
tears [8]. therefore axial to the scapula, but coronal to the
humerus. ABER imaging aids in the assessment
of the anteroinferior and posterosuperior
2.1.3 Provocative Positioning labrum.
For imaging in the ADIR position, the arm is
Provocative positioning such as abduction exter- placed behind the patient’s back with the patient
nal rotation (ABER), flexion-adduction internal in the supine position and the shoulder coil placed
rotation (FADIR), and adduction internal rotation anterior to the shoulder. Although fewer studies
(ADIR) have been shown to be helpful in the have evaluated the efficacy of this position, it has
evaluation of the labroligamentous complex and been shown to aid in the diagnosis of anterior
in the detection of subtle labroligamentous inju- labroligamentous periosteal sleeve avulsion
ries, particularly when using MR arthrography lesions (ALPSA) of the anteroinferior labrum
[9, 10] (refer to the “Arthrography” section of and Bankart subtypes [11].
this chapter). The arm is placed across the chest on top of
For the ABER view, the affected shoulder is the contralateral shoulder with the palm facing
abducted and externally rotated, with the fore- outward for the FADIR position. Imaging in the
arm tucked behind the patient’s head while lying FADIR position has been shown to increase
a b
Fig. 2.4 ABER position. (a) The patient is supine with the to maintain position during the scan. (b) ABER MR
elbow flexed and their hand behind the head. The coil is images are prescribed from the coronal localizer along the
placed overlying the axillary region with a sandbag/weight long axis of the humerus to produce axial oblique images
a b
Fig. 2.5 FADIR position. FADIR MR images are prescribed from the coronal localizer to produce axial images
diagnostic confidence in the evaluation of the 2.2 ormal MR Appearance

N
posteroinferior labrum (Fig. 2.5) [12]. of the Shoulder
In 1999, Wintzell and colleagues found that
when the arm is abducted at 90° and maximally 2.2.1 Bones
extended, capsulolabral lesions were better eval-
uated compared to ABER positioning [13]. The osseous structures imaged on a conventional
SLAP lesions have been found to be better shoulder MR examination are the clavicle, scap-
assessed when the arm is held in external rota- ula, and humerus. Because of fat within marrow,
tion with traction using 3 kg weights [14]. the medullary cavity normally demonstrates
Internal and external rotation has also shown to hyperintense signal on T1-weighted images.
be helpful in the evaluation of subcoracoid After birth, hematopoietic red marrow converts
impingement [15]. into yellow fatty marrow, beginning in the
a b c
Fig. 2.6 Normal marrow signal intensity. (a) Coronal tense, T2 hyperintense signal within the proximal humeral
T1-weighted, (b) T2-weighted fat-suppressed, and (c) metaphysis and extending into the imaged diaphysis with
T1-weighted fat-suppressed post-contrast images of the corresponding subtle enhancement, in keeping with red
proximal left humerus demonstrating diffusely T1 hypoin- marrow reconversion
d iaphysis of long bones including the humerus, about 1 mm and is comprised of the coracohu-
followed by the distal metaphysis, and finally the meral ligament in addition to large arterioles.
proximal metaphysis [16]. Hematopoietic (red) Layer II is the thickest layer, measuring 3–5 mm,
marrow can be seen within the proximal humeral and contains densely packed tendon fibers, which
metaphysis to the epiphysis, with a curvilinear directly insert onto the greater tuberosity. Fibers
zone of transition between red and yellow mar- from this layer also contribute to the roof of the
row (Fig. 2.6). In one study, residual hematopoi- biceps sheath. Layer III contains smaller bundles
etic marrow was found in 99% of humeral of collagen fibers oriented at a 45-degree angle to
metaphyses and extended to the epiphysis in 62% one another cross-linking measuring approxi-
[17]. This pattern of marrow distribution is mately 3 mm in thickness. Layer IV is a thin
reached by the third decade, after which recon- layer comprised of loose connective tissue and
version occurs, whereby red marrow is replaced thick collagen fibers as well as the coracohumeral
by yellow marrow. ligament. The deepest layer, layer V, is about
2 mm thick and is comprised of the joint
capsule.
2.2.2 Tendons Collagen within a tendon is dense, restricting
the Brownian motion of water molecules [19].
Tendons, which attach muscle to bone, have high These collagen fibers are aligned with water mol-
collagen content (mostly type I). Five confluent ecules, causing dipole interactions and thus a
histologic layers have been described within the shortened T2 of 1–2 ms. [20, 21] At 3.0T, T1
supraspinatus and infraspinatus tendons [18]. relaxation time is relatively short at 600 ms. [22]
The most superficial layer, layer I, measures Normal tendons consequently demonstrate
hypointense signal on all sequences (Fig. 2.7a). intensity and magic angle artifact has been
As the angle between the collagen fibers within a excluded as the cause, this can be indicative of
tendon and the static magnetic field (B0) increases, tendinosis, particularly when the finding is asso-
the effects of dipole interactions are minimized ciated with thickening (Fig. 2.8) [26]. The sensi-
and T2 increases, resulting in spurious signal tivity of MRI in the detection of tendinosis has
alteration [23]. When the angle reaches 55°, T2 been shown to be up to 55%, with a specificity of
relaxation time is maximized and a normal ten- up to 92.7% [29]. Pseudogap can be seen at the
don can demonstrate increased signal intensity insertion of the supraspinatus tendon near the
known as the “magic angle” artifact (Fig. 2.7b) greater tuberosity, lateral to the myotendinous
[24, 25]. T2-weighted images have been shown junction as a result of differing fiber orientation
to be more dependent on fiber orientation than T1 of the anterior and posterior bundles and their
[26]. Common sites of magic angle phenomenon intrinsic tissue relaxation times (Fig. 2.9) [30].
in the shoulder include the critical zone of the Unlike magic angle artifact, pseudogap is present
supraspinatus, posterosuperior and anteroinferior on all pulse sequences obtained in the coronal
labrum, and intra-articular long head of the oblique plane.
biceps tendon proximal to the intertubercular Occasionally, tendinosis can be difficult to dif-
groove [27]. Imaging with a longer echo time ferentiate from partial-thickness tears [26]. Focal
(TE greater than 37 ms) minimizes magic angle areas of fluid signal intensity along the articular
artifact; therefore this effect is not appreciated on or bursal surfaces or within the tendon substance
T2-weighted and STIR sequences [28]. on fat-suppressed T2 or STIR images are seen
The primary shoulder tendons include with partial-thickness tears (Fig. 2.10). Articular
the rotator cuff, comprised of the supraspinatus, surface tears are the most common type of partial-
infraspinatus, teres minor, and subscapularis ten- thickness rotator cuff tears [31]. When a tendon
dons, as well as the long-head biceps tendon. is completely torn, the torn tendon fibers may be
When a tendon demonstrates increased signal retracted. In chronic tears, scar tissue may
a b
Fig. 2.7 Magic angle artifact. Coronal oblique MR at a TE of 19 ms, (b) which resolves at a TE of 77 ms. The
images from the same patient demonstrate (a) increased finding in (a) is a result of magic angle artifact given the
signal intensity within the supraspinatus tendon (arrows) short TE
a b
Fig. 2.8 Tendinosis. Coronal oblique proton density MR insertional supraspinatus tendon fibers (arrows). No dis-
images (a) without and (b) with fat suppression demon- continuous fibers are seen. The findings are compatible
strate thickening and intermediate signal intensity of the with moderate-severe tendinosis
a b
Fig. 2.9 Pseudogap. Coronal oblique proton density onto the greater tuberosity (circled), (b) which resolves on
image on an asymptomatic patient demonstrating increased the sagittal oblique T2-weighted fat- suppressed image.
signal intensity of the supraspinatus tendon as it inserts The findings in (a) correspond to pseudogap
develop at the site of the tear, resulting in low-to- degenerative changes tend to occur at the junc-
intermediate signal intensity interposed between tion of the supraspinatus and infraspinatus ten-
the torn tendon fibers on all pulse sequences dons [32, 33]. Studies have also reported that
(Fig. 2.11) [26]. The sensitivity of MRI in the degenerative tears primarily involve the articular
detection of rotator cuff tears has been shown to surface and the “critical zone,” the area of vascu-
be up to 92.1% and specificity up to 92.9% [29]. lar anastomosis just proximal to the rotator cuff
Traumatic tears commonly involve the supra- insertion [34]. Both cadaveric and clinical studies
spinatus tendon or rotator interval, whereas found that decreased cellularity, fascicular thin-
a b
Fig. 2.10 Partial-thickness tendon tear. Coronal oblique (a) without and (b) with fat suppression demonstrates fluid-
bright signal at the articular surface of the supraspinatus insertion (arrows) compatible with a partial-thickness tear
ning, disorganization of collagen fibers in layer ments also have an important functional and ana-
III, and decreased vascularity in patients older tomic significance, supporting the glenohumeral
than 40 years are all factors that predispose ten- ligament superiorly. An additional accessory lig-
dons to partial-thickness, articular-surface tears ament known as the spiral ligament, ligamentum
[35]. Intratendinous strain has additionally been glenohumerale, or spirale fasciculus obliquus
described as an important factor in the develop- runs more obliquely along the anterior margin of
ment of partial-thickness tears, with secondary the capsule from the lesser tuberosity and infra-
propagation of tears from the articular to bursal glenoid tubercle to the subscapularis tendon [42].
surface [36–39]. Extrinsic mechanisms of rotator
cuff tearing include subacromial, coracoacro-
mial, and internal impingement [40, 41]. 2.2.4 Labrum
The glenoid labrum rims the glenoid fossa and is

2.2.3 Ligaments predominantly comprised of fibrous connective
tissue. At the junction of the labrum and hyaline
Ligaments connect bone to bone and have high cartilage is dense fibrocartilage tissue. As a result
proteoglycan and water content and low collagen of the lack of mobile protons in such dense tissue,
content [22]. Accordingly, ligaments are hypoin- the normal glenoid labrum is hypointense on all
tense in signal on all pulse sequences. In the pulse sequences (Fig. 2.12). Labral tears are clas-
shoulder, the superior, middle, and inferior gle- sified by morphology, presence or absence of dis-
nohumeral ligaments form the primary ligaments placement, and location. When the labrum
at the anterior aspect of the glenohumeral joint. demonstrates surface irregularity, it may be
The coracoacromial and coracoclavicular liga- frayed or torn. On MRI, fluid signal intensity
a b
Fig. 2.11 Full-thickness, full-width tendon tear. Coronal supraspinatus tendon (arrows) evidenced by a full-
oblique proton density (a) without and (b) with fat sup- thickness, full-width fluid-filled defect and discontinuity
pression, and (c) sagittal oblique T2-weighted fat- of the tendon. The torn tendon fibers are retracted to the
suppressed images on a patient with a complete tear of the level of the glenohumeral joint (asterisk)
within the labral substance extending to the sur- 2.3 Artifacts/Pitfalls

face or fluid signal/contrast imbibition within the
labrum is diagnostic of tear (Fig. 2.13) [43, 44]. The shoulder is best imaged in slight external
The labrum can also be avulsed. The findings rotation. However, both exaggerated external
may be seen in association with paralabral cyst rotation and internal rotation are undesirable
formation, periosteal stripping or tearing, carti- as the tendons shift in position with respect to the
lage defects, and associated bone defects as in the standard imaging planes. The tendons also over-
setting of osseous Bankart lesions [45]. lap, resulting in false-positive tendon tears,
a b
Fig. 2.12 Normal glenoid labrum. (a) Coronal oblique arrow), inferior (short solid arrow), and posterior (short
proton density fat-suppressed and (b) axial T2-weighted dashed arrow) labrum. Note the somewhat more rounded
fat-suppressed (b) images demonstrating a normal configuration of the anterior labrum (long dashed arrow)
hypointense triangular contour to the superior (long solid
a b
Fig. 2.13 Labral tear. (a) Coronal oblique proton den- linear fluid signal intensity within the substance of the
sity fat-suppressed and (b) axial T2-weighted fat-sup- superior (short white arrow) and posterior (long white
pressed images from the same patient demonstrating arrow) labrum
p articularly of the supraspinatus on the coronal 2.3.1 Vacuum Phenomenon

images, where it can appear discontinuous and
the capsule redundant (Fig. 2.14). The anterior When the shoulder is held in traction/extreme
structures may also overlap, resulting in abnormal external rotation, gas has been shown to accumu-
signal intensity within the subscapularis, middle late within the joint and referred to as vacuum
glenohumeral ligament, and capsular structures. phenomenon (Fig. 2.15) [46]. This finding may
be related to the intra-articular accumulation of
nitrogen in the setting of decreasing intra-
articular pressure from traction separating the
apposing articular surfaces [47]. Classically, cur-
vilinear hypointense signal is seen superiorly in
the absence of effusion or abnormal findings that
could suggest septic arthritis. Differentiation of
intra-articular gas from loose bodies, displaced
labral/cartilage fragments, synovial tissue, metal,
and chondrocalcinosis is of key importance.
2.3.2 Chemical Shift Artifact
In addition to the previously described magic

Fig. 2.14 Internal shoulder rotation. Axial T1-weighted
fat-suppressed image of the shoulder in internal rotation angle phenomenon, another artifact commonly
following the intra-articular administration of contrast encountered on MR imaging of the shoulder is
demonstrates medial migration of the middle glenohu- chemical shift artifact. This artifact occurs at the
meral ligament (white arrow), obscuration of the anterior boundary between tissues containing high concen-
labrum (black arrow), apparent thickening and redun-
dancy of the anterior capsule (arrowhead), and increased trations of fat and those containing high concen-
signal intensity and thickening of the subscapularis ten- trations of water, such as within fluid-filled cysts
don falsely suggesting tendinosis (asterisk) and fat-containing lesions, and at the interface of
a b
Fig. 2.15 Vacuum phenomenon artifact. (a) Axial gradi- density sequence subsequently obtained, no corresponding
ent echo image demonstrates a hypointense focus within hypointense focus is seen, in keeping with air in the setting
the glenohumeral joint (circled). (b) On the axial proton of vacuum artifact and not intra-articular calcification
cartilage and bone marrow [48, 49]. It occurs articular injection ranging from 1% to 73% have
because of the different resonance precession fre- been reported [59–61]. Ultrasound, CT, and fluo-
quencies of fat and water, respectively, in the fre- roscopy are effective modalities for image-guided
quency-encoding direction, caused by techniques for direct MR arthrography [62, 63].
inhomogeneity within the main magnetic field. There are four primary image-guided techniques
This effect is exacerbated with increasing field for direct MRA: (1) rotator interval approach
strengths. In the shoulder, signal abnormality at under fluoroscopic guidance, (2) anterior approach
the bone-cartilage interface of the glenohumeral under fluoroscopic guidance, (3) posterior
joint can simulate full-thickness cartilage loss approach under fluoroscopic guidance, and (4)
[50]. Knowledge of chemical shift artifact is thus posterior approach under ultrasound guidance
essential in precluding misdiagnosis of glenohu- (refer to Chap. 6—Image-Guided Procedures in
meral cartilage wear. Chemical shift artifact may the Shoulder).
be reduced by suppressing fat or switching phase Although intra-articular injection of gadolin-
and frequency-encoding directions [51, 52]. ium is not approved by the US Food and Drug
Increasing bandwidth and utilizing lower field Administration (FDA), direct arthrography is
magnets are other alternatives. performed as an off-label technique. Gadolinium
is diluted to a concentration of 1–2 mmol/L typi-
cally with saline to a volume of approximately
2.4 Arthrography 12 mL, although iodinated contrast can be added
to confirm appropriate needle position when per-
MR arthrography (MRA) can be performed fol- forming the study with fluoroscopic guidance
lowing the direct injection of dilute gadolinium [64–66]. While some studies found that the addi-
or saline into the glenohumeral joint, or indirectly tion of iodinated contrast can compromise the
via intravenous injection of gadolinium. signal intensity of gadolinium, others have shown
Structures that otherwise lie in close apposition that a 1:1 mixture of saline with iodinated con-
separate due to distention of the capsule, allow- trast (for example 10 mL each) and 0.1 mL gado-
ing for better assessment. linium does not result in significant dissociation
of the gadolinium ion [10, 67–71]. The advantage
of premixing the dilute gadolinium with iodin-
2.4.1 Direct MR Arthrography ated contrast is that the chance of introducing
bubbles of air when exchanging syringes is non-
Over the past two decades, direct MR arthrogra- existent. However, the addition of iodinated con-
phy has been performed with increasing fre- trast further dilutes the gadolinium concentration,
quency [53, 54]. Direct arthrography outlines the resulting in a lower signal intensity of the con-
fine intra-articular structures including the trast [72]. This effect is exaggerated at 3.0T
labrum, undersurface of the rotator cuff, and cap- because the signal-to-noise ratio peak levels for
sule by distending the joint [54–58]. It is most iodinated contrast dilutions are relatively lower
commonly performed on patients younger than than at 1.5T. Although complications of direct
35 years or in the setting of prior surgery, shoul- MR arthrography are rare, infection, bleeding,
der instability, labral tear (particularly SLAP allergic reaction, synovitis, and pain have been
lesions), and to determine whether there is a described.
partial- versus full-thickness rotator cuff tear

when noncontrast MRI is inconclusive. 2.4.1.2 Imaging Technique
Imaging can be performed up to approxi-
2.4.1.1 Gadolinium Dilution mately one hour following the shoulder injec-
Dilute contrast can be injected into the glenohu- tion. With dilute gadolinium, T1-weighted
meral joint via a blind approach with palpation of fat-suppressed images are commonly obtained,
anatomical landmarks, but variable rates of extra- whereas intermediate and T2-weighted spin-
Table 2.2 Protocol for direct MR arthrography of the shoulder

Coronal T1 FS 400–800 Min 3.0–4.0 140 × 140 500 × 700
Coronal T2 FS 3500–5000 40–80 3.0–4.0 140 × 140 500 × 500
Sagittal T1 400–800 Min 3.0 140 × 140 500 × 500
Axial T1 FS 400–800 Min 3.0–4.0 140 × 140 500 × 700
ABER/ADIR 450–700 Min 4.0 140 × 140 500 × 700
FS fat suppression, ABER abduction external rotation, ADIR adduction internal rotation
echo sequences are performed following nor-

mal saline injection. At our institution, five
sequences are typically obtained following intra-
articular dilute gadolinium injection: axial and
coronal oblique T1-weighted fat-suppressed,
coronal oblique T2-weighted fat-suppressed, sag-
ittal T1-weighted, and an axial T1-weighted fat-
suppressed sequence in the abducted/externally
rotated position (ABER view; Table 2.2).
Lee and colleagues advocate an additional
gradient echo sequence in order to improve
sensitivity for anterior and posterior labral
tears relative to T1-weighted images alone,
with sensitivities of 78% and 75% for the gra-
dient echo sequences relative to 25% and 56%
for T1-weighted images, respectively [73]. No
significant difference was seen between the
Fig. 2.16 Full-thickness tendon tear on MR arthrography.
two sequences for superior labral tears in that Coronal oblique T1-weighted fat-suppressed image follow-
study. ing intra-articular administration of dilute gadolinium shows
Direct gadolinium MR arthrography is preferred extravasation of contrast into the subacromial-subdeltoid
bursa via a full-thickness tear at the insertion of the supraspi-
to direct saline injection because of significant
natus tendon (white arrow) with discontinuity and medial
improvement in image quality and signal-to-noise retraction of the torn tendon fibers (black arrow)
ratio of the T1 images obtained, compared to the
T2-weighted images obtained in the saline injection
studies. In addition, it is impossible to distinguish
ligament is placed under tension (Fig. 2.17).
between injected saline and bursal fluid; as such, no
ABER views also aid in the evaluation of supe-
diagnostic criterion exists to differentiate between
rior and posterosuperior labral tears, partial-
partial- and full-thickness tears. Fat-suppressed thickness articular surface tears of the
images are preferred in direct gadolinium MR insertional supraspinatus and infraspinatus ten-
arthrography in order to distinguish fat within the
dons, suspected posterosuperior impingement,
subacromial-subdeltoid bursa and the intra-articular
and subtle glenohumeral joint subluxations
contrast, which would indicate a full-thickness rota-
(Figs. 2.18 and 2.19). When used in conjunc-
tor cuff tear (Fig. 2.16). tion with the standard direct MR arthrography
protocol, the ABER view has been shown to
2.4.1.3 Provocative Imaging increase sensitivity and specificity for anterior
Anteroinferior labral tears are more conspicu- labral tear detection from 48% and 91% to 96%
ous on ABER views, particularly after the intra- and 97%, respectively [10]. Studies have also
articular administration of gadolinium because shown that in patients who cannot tolerate long
the anterior band of the inferior glenohumeral MR scans, the ABER view in a direct MR
a b
Fig. 2.17 Anteroinferior labral tear on direct MR (arrow). (b) ABER image subsequently obtained on the
arthrography. (a) Axial T1-weighted fat-suppressed same patient reveals a contrast-filled cleft at the chondro-
image from a direct MR arthrogram demonstrates a labral junction of the anteroinferior labrum (arrow),
normal-
appearing labrum without contrast imbibition reflecting tear
a b
Fig. 2.18 Superior labral tear on direct MR arthrogra- of dilute gadolinium with contrast extension into the sub-
phy. (a) Coronal oblique and (b) ABER T1-weighted fat- stance of the superior labrum (arrows), reflecting a non-
suppressed images following intra-articular administration displaced labral tear
arthrogram alone is as accurate as an entire con- conspicuity of posterior labral tears and
ventional MR arthrogram examination in the improve assessment of the posterior joint cap-
diagnosis of rotator cuff tear [74]. sule with intra-articular contrast distension
Additional FADIR MR imaging can increase (Fig. 2.20).
a b
Fig. 2.19 Posteroinferior labral tear on direct MR stripping of the periosteum from the posterior glenoid,
arthrography. (a) Axial and (b) ABER T1-weighted fat- which remains attached to the displaced labral tissue
suppressed images following intra-articular administra- (solid arrow), in keeping with posterior labrum periosteal
tion of dilute gadolinium show extension of contrast at the sleeve avulsion (POLPSA). Note that there is also a thin
posteroinferior chondrolabral junction in association with chain of paralabral cysts (dashed arrow)
a b
Fig. 2.20 Posterior labral tear on FADIR direct MR rior labrum (arrow) dissecting to the capsulolabral junc-
arthrography. (a) Axial T1-weighted fat-suppressed tion. (b) This finding is slightly more conspicuous on
image following intra-articular contrast administration the FADIR image (arrow)
demonstrates subtle contrast imbibition within the poste-
2.4.1.4 Advantages and Disadvantages raphy [75]. MR arthrography has been shown to
Compared to conventional noncontrast MR imag- improve the accuracy of detection of supraspinatus
ing of the shoulder, subtle tears within the rotator and subscapularis abnormalities when compared
cuff are more conspicuous with direct MR arthrog- with standard MR imaging [75, 76].
Waldt and colleagues demonstrated a sensitiv- embrane permeability, and presence/absence

m
ity of 88%, specificity of 91%, accuracy of 89%, of a joint effusion. In the setting of trauma,
and negative and positive predictive values of 88 rheumatoid arthritis, or infection for example,
and 91%, respectively, with regard to direct MR the permeability of the synovial membrane is
angiography and detection of anteroinferior increased, resulting in halved transit time of
labral tears [77]. Using arthroscopy as the refer- contrast into the joint [82]. Conversely, synovial
ence standard, direct MR arthrography showed a fibrosis would increase the time for contrast to
sensitivity of 82% and specificity of 98% in the enter the joint space. When a joint effusion is
identification of SLAP tears [78]. present, because of pressure differences, the rate
Direct MR arthrography has some disadvan- at which contrast enters the joint space is
tages. Gianconi and colleagues studied 135 decreased and imaging delay times may be
patients who underwent direct MR arthrography increased by 50% when a hemorrhagic or septic
and found that 66% experienced transient but sig- effusion is present [54]. Some authors advocate
nificant delayed-onset pain in the joint [79]. exercise of approximately 10 minutes following
Nonspecific side effects such as allergic reaction the intravenous injection of contrast prior to
to gadolinium or local anesthetic as well as vaso- imaging in order to promote blood flow to the
vagal reactions and nausea have also been joint [84, 87, 88]. Other studies have shown that
described [80]. Bleeding and infection are rare application of heat or ultrasound can also
complications [80, 81]. increase the concentration of gadolinium within
joints [89, 90].
2.4.2 Indirect MRA 2.4.2.1 Imaging Technique

At our institution, five sequences are typically
Indirect MR arthrography offers a noninvasive obtained following a 10–15-minute period of exer-
alternative to direct MR angiography. It is based cise involving repetitive shoulder rotation, abduc-
upon the concept that vessels and the intra-articular tion, and adduction: axial and coronal oblique
space enhance and demonstrate comparable signal T1-weighted fat-suppressed, sagittal oblique
intensity following the administration of intrave- T1-weighted, coronal oblique T2-weighted fat-
nous contrast [82]. Because of the principles of suppressed, and an axial T1-weighted fat-
bulk flow and diffusion, and lack of a basal mem- suppressed sequence in the abducted/externally
brane in the synovial lining, intravenous adminis- rotated position (ABER view, Table 2.3). As with
tration of gadolinium at a concentration of direct MR arthrography, provocative imaging can
0.1 mmol/kg eventually enters the joint space probe performed to increase diagnostic accuracy.
ducing an arthrographic effect [83–86]. Since Imaging 15 minutes following intravenous
intravenous gadolinium diffuses from the capillary injection of contrast material improves the sensi-
bed into the synovium and then enters the joint tivity and detection of shoulder pathology [82,
space over time, MR images are typically obtained 84]. Studies have reported sensitivities and speci-
after a delay of approximately 15 minutes. ficities ranging from 67% to 100% and 75% to
The rate at which contrast leaks into the joint 100%, respectively, in the assessment of supra-
is dependent upon vascularity, synovial spinatus and infraspinatus tears, with higher val-
Table 2.3 Protocol for indirect MR arthrography of the shoulder

Coronal T1 FS 400–800 8.6 4.0 140 × 140 500 × 500
Coronal T2 FS 3500–5000 55–80 4.0 140 × 140 500 × 500
Sagittal T1 400–800 9.4 4.0 140 × 140 500 × 500
Axial T1 FS 400–800 Min 4.0 140 × 140 500 × 500
ABER/ADIR 450–600 Min 3.0–4.0 140 × 140 500 × 700
ues seen for full-thickness supraspinatus tears

and greater variation for partial-thickness tears
[91–95]. High sensitivity and specificity have
been reported for the evaluation of delaminating
supraspinatus and infraspinatus tendon tears
[96]. 64–67% sensitivity and 75–88% specificity
have been reported for assessment of subscapu-
laris tendon tears [94, 95]. As with direct MR
arthrography, because of tension on the labrum
with stretching of the inferior glenohumeral liga-
ment in the ABER position, anteroinferior labral
tears become more conspicuous as compared
with neutral imaging. Herold and colleagues
found that ABER views improved sensitivity and
diagnostic confidence in the detection of partial-
thickness supraspinatus tendon tears [92].
When compared to conventional noncontrast
MRI, anterior labral tears can be more easily Fig. 2.21 Labral tear on indirect MR arthrography.
Axial T1-weighted fat-suppressed image from an indirect
detected, although, studies have reported lower MR arthrogram demonstrates slightly increased signal at
sensitivity and specificity in the detection of the base of the anterior labrum, suggestive of tear (arrow).
superior labral tears on indirect MR arthrography Without distension of the joint, it is unclear if this is indic-
(Figs. 2.21 and 2.22) [95]. The diagnosis of labral ative of a stable, healing tear with enhancing granulation
tissue within the cleft versus an unstable lesion. Note that
tears on indirect MR arthrography can, however, there is also linear enhancement at the base of the poste-
be challenging due to the lack of capsular disten- rior labrum reflecting tear in this patient (arrowhead)
sion and is consequently highly dependent on the
amount of native fluid within the joint for arthro-
graphic effect. Fallahi and colleagues demon-
strated 95–97% sensitivity for labral tear with
indirect MRI versus 79–83% for conventional
MRI. Diagnostic accuracy also increased from
84–86% to 93–95% from conventional to indirect
MRI [97]. In one study, indirect MR arthrogra-
phy had sensitivities and specificities comparable
to those of direct MR arthrography in the assess-
ment of labral tears [94].
2.4.2.2 Advantages and Disadvantages

There are several advantages to indirect MR
arthrography. In comparison to direct MR angi-
ography, it is less invasive and less time
consuming, not requiring image guidance or

iodinated contrast material.
Vessels, postoperative granulation tissue, ten-
don sheaths, and other synovial-lined structures
including the shoulder bursae are some of the Fig. 2.22 Superior labral tear on indirect MR arthrogra-
phy. Coronal oblique T1-weighted fat-suppressed image
normally enhancing structures. Since the joint from an indirect MR arthrogram with linear enhancement
compartments also enhance, it is difficult to iden- within the substance of the superior labrum (arrow)
tify abnormal communication between them reflecting a nondisplaced tear
a b
Fig. 2.23 False-negative full-thickness supraspinatus gin, indicating a full-thickness tear (arrow). However, the
tendon tear on indirect MR arthrography. (a) Coronal corresponding (b) coronal oblique T2-weighted fat-
oblique T1-weighted fat-suppressed image from an indi- suppressed image shows that the bursal surface fibers are
rect MR arthrogram demonstrates enhancement without actually intact and enables differentiation between the
discrete continuous insertional supraspinatus tendon fibers subacromial-subdeltoid bursa and torn tendon (arrow) by
and lack of the normal linear dark signal at the tendon mar- the intervening intact bursal surface fibers (dashed arrow)
resulting in the potential for misinterpretation intra-articular fluid does not demonstrate as high
[82]. As a result, unlike in direct MR arthrogra- of a signal intensity.
phy, enhancement of the subacromial-subdeltoid Side effects from intravenous gadolinium con-
bursa cannot be considered an indirect sign of trast are rare and the more common of these
full-thickness rotator cuff tear (Fig. 2.23) [54]. include nausea, vomiting, allergy, and hypersen-
This fact makes identifying bursal sided partial sitivity reactions [99]. This study is contraindi-
tears easier [84, 92]. cated in patients with poor renal function due to
Because infection, inflammation, and tears all the risk of nephrogenic systemic fibrosis.
enhance, it is important to be able to distinguish
between these three conditions. Song and col-
leagues found that the axillary joint capsule is 2.5 Three-Dimensional Imaging
increasingly thickened and demonstrates greater
enhancement in the setting of adhesive capsulitis With respect to the shoulder, 3D MR sequences
due to inflammation with resultant hyperemia have been utilized in the assessment of the articu-
and fibrosis [98]. Increased enhancement within lar cartilage typically using fast imaging with
the rotator interval has also been described steady-state precession (FISP), double-echo
(Fig. 2.24). steady-state (DESS), spoiled gradient recalled
This method does not distend the joint capsule echo, and gradient echo sequences. 3D fast gradi-
so indirect MR arthrography may suffer when ent echo isotropic images offer shorter scan times
there is scant native joint fluid. Furthermore, and have been shown to provide the same clinical
when compared with direct MR arthrography, the information as conventional imaging [100].
a b
Fig. 2.24 Adhesive capsulitis. (a) Coronal oblique pouch (arrows) with infiltration of the fat within the rota-
T1-weighted fat-suppressed and (b) sagittal oblique tor interval (asterisk), which can be seen in the setting of
T1-weighted images from an indirect MR arthrogram adhesive capsulitis
demonstrate thickening and enhancement of the axillary
Three-dimensional imaging has also been when comparing 3D gradient echo isotropic and
shown to be useful with MR arthrography. With conventional FSE sequences.
direct MR arthrography, fat-suppressed gradient Additionally, 3D MRI has been shown to be
echo images have been found to be more sensitive effective in the measurement of glenoid bone loss
than conventional spin-echo T1-weighted images in the setting of anterior shoulder instability/dis-
in the detection of glenoid labral tears, particu- location (Fig. 2.25). Utilizing the best-fit circle
larly posterior labral tears [101]. Lee and col- method, Gyftopoulos and colleagues found no
leagues found no statistical difference in the statistically significant difference between inter-
detection of superior labral tears. Jung and col- pretation of axial 3D echo time T1-weighted
leagues found no significant difference in diag- FLASH sequences with Dixon-based water-fat
nostic accuracy, sensitivity, or specificity of labral separation for glenoid defect measurements rela-
tear detection between 3D fat-suppressed fast tive to intraoperative findings [103]. In addition,
GRE using an isotropic voxel size of 0.6 mm with no statistically significant difference was found
an imaging time of 5 minutes 30 seconds and con- between these 3D MR reconstructions and 3D
ventional fast spin-echo (FSE) sequences [102]. CT reconstructions with respect to glenoid and
Magee showed that in addition to offering humeral head bone loss [104].
decreased scan times less than 3 minutes, 3D fast-
spoiled gradient echo fat-suppressed isotropic
(voxel size of 0.4 mm) imaging provided the same 2.5.1 The Postoperative Shoulder
clinical information as conventional T1-weighted
MR imaging at 3.0T [100]. In 3.0T indirect MR Twenty five percent of patients who have under-
arthrography, Oh and colleagues found no statisti- gone surgery to repair rotator cuff defects com-
cally significant difference in sensitivity or speci- plain of persistent symptoms with a 20–47%
ficity in the diagnosis of rotator cuff or labral tear prevalence of recurrent or persistent tearing
a c
Fig. 2.25 3D imaging. (a) Axial T1-weighted and (b) 3D dislocations. Sagittal oblique T1-weighted sequence
images demonstrating a large Hill-Sachs deformity shows a corresponding osseous Bankart injury
(arrows) in this patient with recurrent anterior shoulder (arrowhead)
[105–109]. As one would expect, the larger the of repair, periprosthetic loosening and fracture,
tear, the greater the symptoms [108–110]. These dislocation and instability, and scapular notching
symptomatic patients tend to have a shorter inter- (in the setting of reverse total shoulder arthro-
val between their initial presentation and surgical plasty) [112–114]. Ultrasound can be used in iso-
repair [111]. Zanetti and colleagues found that lation or as an adjunct to evaluate the adjacent
although 47% of symptomatic patients have post- soft tissues and evaluate for rotator cuff tear or
operative rotator cuff tears, 21% of asymptomatic nerve injury [115–117]. Nuclear medicine stud-
patients do, as well [105]. ies may also be performed in the setting of infec-
Radiographs and CT are the preferred initial tion, although aspiration is recommended early in
imaging modalities for patients who have under- the diagnostic algorithm. Despite the fact that
gone surgery to identify the source of pain. Some MR imaging offers superior contrast and spatial
postoperative complications include breakdown resolution, because of artifact related to the
metallic hardware and residual metal shavings paramagnetic metal alloys that are MR compati-
from the surgical instruments and postoperative ble, resulting in less metal-related artifact. With
anatomic distortion, it has not traditionally been the advent of metal reduction protocols, MR
used in post-arthroplasty patients. imaging is an additional helpful imaging test,
offering evaluation not only for capsular or nerve
2.5.1.1 Metal Reduction Protocols injury and tears of the rotator cuff, but also for
One of the primary technical considerations when hardware-related complications including oste-
imaging postoperative patients is the presence or olysis, fracture, and loosening [122, 123].
absence of hardware as well as its composition, as Metal reduction protocols minimize artifact by
the degree of susceptibility artifact is dependent decreasing slice thickness and time to echo (TE),
upon ferromagnetism. Because bioabsorbable and increasing the matrix size and bandwidth
suture anchors are nonmetallic, there is no associ- [120]. Decreasing the TE offers less time for the
ated susceptibility artifact. Some of the complica- protons to dephase, thereby preventing misregis-
tions of these sutures include loosening/detachment, tration-related artifact [124]. Increasing the matrix
osteolysis, cyst formation, adjacent inflammation, size decreases the size of the pixels, which
and infection (Fig. 2.26) [118–120]. decreases the conspicuity of signal-related arti-
Most hardware currently used in arthroscopic fact. Swapping the phase and frequency-encoding
shoulder surgeries is made of titanium. Metallic gradients and aligning the frequency- encoding
susceptibility artifact is most pronounced with gradient along the longitudinal axis of the prosthe-
ferromagnetic metals like cobalt-chrome and sis are among some of the technical strategies uti-
stainless steel, which were more commonly used lized in MR imaging of hardware [125, 126].
in the past. These change the phase and frequency While increasing the bandwidth decreases the
of local spins, causing a loss in signal and distor- interecho spacing, echo time and thus scan time,
tion along the frequency-encoding axis blurring, and chemical shift, it comes at a cost of
(Fig. 2.27a) [121]. Titanium and zirconium are compromising image quality by way of decreasing
a b
Fig. 2.26 Bioabsorbable suture anchor. (a) Coronal lation tissue, commonly seen following bioabsorbable
oblique proton density and (b) STIR MR images demon- suture anchor repair. Note that bioabsorbable suture
strate lobulated signal hyperintensity (arrows) surround- anchors do not result in artifact severe enough to preclude
ing a bioabsorbable suture anchor within the humeral appropriate diagnostic evaluation versus metallic suture
head that may be related to screw osteolysis versus granu- anchors
a b
Fig. 2.27 Loosening. (a) Conventional axial STIR image image of the same patient has much less associated arti-
in a patient status post-left total shoulder arthroplasty with fact and as a result a small amount of fluid signal intensity
shoulder pain and limited range of motion. Image inter- is more conspicuous along the lateral bone prosthesis
pretation is markedly limited due to susceptibility artifact interface (arrow), concerning for early loosening
from the metal hardware. (b) An axial STIR SEMAC
the signal-to-noise ratio [125]. To compensate for 136]. SEMAC is a modified spin-echo sequence
this, the number of excitations (NEX) is concur- that extends VAT and slice-direction phase
rently increased. Because susceptibility artifact (z-phase) encoding to correct artifacts [128].
increases with increasing magnetic field strength, MAVRIC is a modified fast spin-echo sequence
patients should not be imaged on 3.0T scanners. that acquires multiple image datasets at different
Susceptibility artifact is also exaggerated when frequency bands, offset from the dominant proton
the shoulder is eccentric to the isocenter of the frequency. Both SEMAC and MAVRIC have
bore of the magnet [122]. shown to effectively reduce metal-related artifact
Gradient echo, chemical fat-suppressed, and when compared with fat spin-echo imaging [133].
spin-echo sequences should be avoided as these The MAVRIC protocol has demonstrated improved
amplify susceptibility artifact. These sequences imaging of the implant-bone and -soft tissue inter-
lack the 180-degree refocusing pulse, caus- faces, enabling the diagnosis of synovitis, rotator
ing field inhomogeneity and distortion, and are cuff tears, and periprosthetic bone-related compli-
prone to loss of signal intensity [127–130]. Fast cations [122, 132]. Hybrid MAVRIC-SEMAC pro-
spin-echo sequences may be used instead of stan- tocols have also been described [137].
dard spin-echo sequences. Short tau inversion
recovery (STIR) sequences offer more homoge- 2.5.1.2 Direct MR Arthrography
neous suppression of the fat adjacent to the metal- MR arthrography in the postoperative shoulder is
lic hardware and are the preferred fat-suppressed useful for delineation of the labroligamentous
sequence in the postoperative patient [131]. structures, rotator cuff, and tendons [124].
Advanced MRI techniques for artifact reduction Although conventional noncontrast MRI has an
in high magnetic fields such as SEMAC (slice accuracy of 83–90% in the detection of full-
encoding for metal artifact correction), VAT (view thickness rotator cuff tears after repair, direct MR
angle tilting), and MAVRIC (multiacquisition vari- arthrography has been shown to improve diag-
able-resonance image combination) enable useful nostic accuracy when compared with noncontrast
imaging around implants (Fig. 2.27b) [128, 132– MRI in the postoperative patient [138, 139].
Partial- and full-thickness rotator cuff tears However, this is not always a reliable finding
are both reliably diagnosed in the postopera- as sometimes postoperative scarring can pre-
tive shoulder after intra-articular distension of vent leakage of contrast into the bursa with
the joint, with contrast filling the partial-thick- full-thickness tears [143–145]. In the setting of
ness defect or coursing through the full-thick- full-thickness tears, MR arthrography more
ness defect into the subacromial-subdeltoid reliably identifies medial retraction of the torn
bursa (Figs. 2.28 and 2.29) [140–142]. tendon fibers [124].
a b
Fig. 2.28 Postoperative partial-thickness rotator cuff ity of the articular sided insertional fibers extending to the
tear. (a) Coronal oblique STIR and (b) proton density MR intrasubstance fibers of the supraspinatus tendon (arrows)
images demonstrate fluid signal intensity and discontinu- compatible with partial-thickness tear
a b
Fig. 2.29 Postoperative full-thickness rotator cuff tear. discontinuous fibers and contrast extravasation via the
(a) Coronal oblique T2-weighted fat-suppressed and (b) defect into the subacromial-subdeltoid bursa (arrows).
T1-weighted images from a direct MR arthrogram in a Note that there is increased signal surrounding the bioab-
patient status post-rotator cuff repair with recurrent shoul- sorbable suture anchor, which may reflect granulation tis-
der pain and limited range of motion demonstrate a full- sue and/or osteolysis (arrowhead)
thickness tear of the supraspinatus tendon with
a b
Fig. 2.30 Postoperative anterior labral tear, noncontrast distension precludes assessment for retear/stability. (b)
vs. direct MR arthrography. (a) Axial proton density An axial T1-weighted fat-suppressed image from direct
image from a noncontrast MRI in a patient status post- MR arthrogram on the same patient reveals absence of the
anterior labral debridement shows abnormal signal inten- anterior labrum due to tear with stripping of the anterior
sity of the subchondral bone (arrow) related to postsurgical glenoid periosteum (arrow)
changes from the suture anchor; however, lack of joint
Direct MR arthrography has shown 100% sen-

sitivity in recurrent labral tear detection, com-
pared to 71% in noncontrast MR, although the
findings are less specific- 60% for direct MR
arthrography and 80% for noncontrast MR
(Figs. 2.30 and 2.31) [146].
2.5.1.3 Indirect MR Arthrography

Gadolinium is administered intravenously at a con-
centration of 0.1 mmol/kg and MR is performed
following a delay of 30 minutes. Because postop-
erative granulation tissue enhances and the signal-
to-noise ratio is lower with indirect MR arthrography,
evaluation of the surgical bed can be challenging
(Figs. 2.32 and 2.33). Wagner and colleagues stud-
Fig. 2.31 Displaced labral tear on direct MR arthrogra- ied 24 patients status post surgery for shoulder
phy. Coronal oblique T1-weighted fat-suppressed image
from a direct MR arthrogram in a patient status post instability with symptoms of recurrent instability,
anteroinferior labral repair (asterisk identifies the suture and performed conventional noncontrast MR, direct
anchor) demonstrates a hypertrophied torn labral frag- MR arthrography, or indirect MR arthrography
ment (arrow) displaced into the inferior aspect of the joint, [146]. In this study, indirect MR arthrography was
made conspicuous by the intra-articular contrast
100% accurate in identifying labral tears, greater
than that for the other two imaging tests.
Fig. 2.32 Postoperative indirect MR arthrography. (a) natus (black arrow) and infraspinatus tears (not shown) with
Coronal oblique proton density image demonstrating a full- high-grade fatty infiltration of the infraspinatus muscle
thickness tear of the supraspinatus tendon with retraction to (circled). (c) Subsequent coronal (left) and axial (right)
the level of the glenohumeral joint (white arrow). A com- T1-weighted fat-suppressed images from indirect MR
plete infraspinatus tendon tear was also present (not visual- arthrography show diffuse enhancement of the glenohumeral
ized). Five months following rotator cuff repair, the patient joint (arrowheads). Because both infection and inflammation
returned with complaints of shoulder pain and (b) coronal enhance, it is difficult to distinguish between chronic synovi-
proton density (left) and sagittal T1-weighted (right) images tis and infection on indirect MR arthrography
obtained at this time redemonstrate full-thickness supraspi-
Fig. 2.33 Postoperative infection. (a) Coronal ing abscess formation and marked enhancement of the
oblique (left) and sagittal oblique (right) T1-weighted fat- synovium. (b) Coronal oblique T1-weighted fat-
suppressed images from an indirect MR arthrogram in a suppressed image from an indirect MR arthrogram on the
patient status post-rotator cuff repair with pain and fever. same patient two months following treatment demon-
The suture anchor (black arrow) protrudes beyond the cor- strates interval removal of the suture anchor (white arrow)
tex of the humeral head as a result of loosening in the with very little residual edema and enhancement at the
setting of infection, with reactive marrow edema and suture track. The abscesses have also resolved
pockets of peripherally enhancing fluid (asterisk) reflect-
2.6 Biochemical Imaging methods for detecting early changes in articular

cartilage and fibrocartilage [66, 147]. Although
With recent advances in field strength and coil much of the research has been focused on the
design, researchers are focused on using knee given the presence of thick, flat cartilage
biochemical-
based MRI to identify sensitive and prevalence of knee osteoarthritis in the gen-
eral population, there have been studies investi- collagen in the superficial and radial zones
gating the applicability of biochemical imaging where T2 values are shorter. Studies have shown
to the glenohumeral cartilage and glenoid the feasibility of T2* mapping of cartilage in the
labrum [148–152]. In the clinical setting, these glenohumeral joint [149]. Lee and colleagues
techniques may enable early diagnosis and man- demonstrated differences in T2 values not only
agement of osteoarthritis by targeting proteo- between subjects with and without osteoarthri-
glycan content as well as collagen orientation tis, but also between primary and secondary
and concentration. Research has already dem- osteoarthritis [155].
onstrated successful in vivo monitoring of col-
lagen and proteoglycan content in patients who
have undergone articular cartilage repair in the References
knee [153].
T1 rho, T2* mapping, sodium MRI, and 1. Davis SJ, Teresi LM, Bradley WG, et al. Effect of arm
rotation on MR imaging of the rotator cuff. Radiology.
delayed gadolinium-enhanced MRI of cartilage 1991;181:265–8.
(dGEMRIC) are some of the techniques used to 2. Magee T, Shapiro M, Williams D. Comparison of high-
assess the ultrastructure of cartilage, detecting field-strength versus low-field-strength MRI of the
changes before gross morphological changes can shoulder. AJR Am J Roentgenol. 2003;181:1211–5.
3. Shellock FG, Bert JM, Fritts HM, Gundry CR, et al.
be appreciated on conventional MRI. Both T1 Evaluation of the rotator cuff and glenoid labrum
rho and dGEMRIC evaluate the glycosaminogly- using a 0.2-Tesla extremity magnetic resonance (MR)
can content of articular cartilage. system: MR results compared to surgical findings. J
For dGEMRIC studies, FSE IR T1-weighted Magn Reson Imaging. 2001;14:763–70.
4. Spencer BA, Dolinskas CA, Seymour PA, Thomas
MR imaging is performed on a 1.5T scanner 30 SJ, Abboud JA. Glenohumeral articular cartilage
and 90 minutes following a double-dose intrave- lesions: prospective comparison of non-contrast mag-
nous injection of gadolinium at a dose of netic resonance imaging and findings at arthroscopy.
0.2 mmol/kg and a brief period of exercise Arthroscopy. 2013;29:1466–70.
5. VanBeek C, Loeffler BJ, Narzikul A, et al.
(approximately 10 minutes). The principle behind Diagnostic accuracy of noncontrast MRI for detec-
dGEMRIC studies is that negatively charged gad- tion of glenohumeral cartilage lesions: a prospec-
olinium replaces the extra-cellular negatively tive comparison to arthroscopy. J Shoulder Elb Surg.
charged glycosaminoglycan molecules, which 2014;23(7):1010–6.
6. Legan JM, Burkhard TK, Goff WB II, et al. Tears of
are depleted in early degeneration of cartilage. the glenoid labrum: MR imaging of 88 arthroscopi-
Thus, measuring T1 relaxation times following cally confirmed cases. Radiology. 1991;179:241–6.
the intravenous administration of gadolinium 7. Phillips JC, Cook C, Beaty S, et al. Validity of non-
creates a map of glycosaminoglycan depletion, contrast magnetic resonance imaging in diagnosing
superior labrum anterior-posterior tears. J Shoulder
with the concentration of gadolinium per voxel Elb Surg. 2013;22(1):3–8.
(T1gd or dGEMRIC index) being low in areas of 8. Magee TH, Williams D. Sensitivity and specificity in
low glycosaminoglycan content and vice versa. detection of labral tears with 3.0-T MRI of the shoul-
Wiener and colleagues found a decrease in T1gd der. AJR. 2006;187:1448–52.
9. Kwak SM, Brown RR, Resnick D, et al. Anatomy, ana-
15 minutes after intra-articular injection of gado- tomic variations, and pathology of 11- to 3-o'clock posi-
linium, with increased uptake in hyaline versus tion of the glenoid labrum: findings on MR arthrography
labral cartilage [148]. and anatomic sections. AJR. 1998;171:235–8.
T1 rho studies have demonstrated an 10. Cvitanic O, Tirman P, Feller J, et al. Using abduction
and external rotation of the shoulder to increase the
inversely proportional relationship between T1 sensitivity of MR arthrography in revealing tears of
relaxation time in the rotating frame and glycos- the anterior glenoid labrum. AJR. 1997;169:837–44.
aminoglycan content [154]. T2* mapping takes 11. Song JC, Lazarus ML, Song AP. MRI findings in Little
advantage of the zonal structure of collagen to Leaguer’s shoulder. Skelet Radiol. 2006;35(2):107–9.
12. MM C, Harish S, Burr J. MR arthrographic assess-
map out T2 values in articular cartilage. For ment of suspected posteroinferior labral lesions using
example, collagen in the intermediate zone is flexion, adduction, and internal rotation positioning
organized in a random fashion, resulting in lon- of the arm: preliminary experience. Skelet Radiol.
ger T2 values compared to the more organized 2010;39(5):481–8.
13. G W, Haglund-Akerlind Y, Larsson H. Open MR 30. Vahlensieck M, Pollack M, Lang P, et al. Two
imaging of the unstable shoulder in the apprehen- segments of the supraspinous muscle: cause of
sion test position: description and evaluation of an high signal intensity at MR imaging? Radiology.
alternative MR examination position. Eur Radiol. 1993;186(2):449–54.
1999;9(9):1789–95. 31. Resnick D, Kang HS, Pretterklieber ML. Shoulder.
14. Chan KK, Muldoon KA, Yeh L, et al. Superior labral In: Resnick D, Kang HS, Pretterklieber ML, editors.
anteroposterior lesions: MR arthrography with arm Internal derangements of joints. 2nd ed. Philadelphia,
traction. AJR. 1999;173(4):111–1122. Pennsylvania: Elsevier; 2007. p. 713–1122.
15. Friedman RJ, Bonutti PM, Genez B. Cine mag- 32. Guckel C, Nidecker A. Diagnosis of tears in rotator-
netic resonance imaging of the subcoracoid region. cuff injuries. Eur J Radiol. 1997;25(3):168–76.
Orthopedics. 1998;21:545–8. 33. Kim HM, Dahiya N, Teefey SA, et al. Location and
16. Siegel MJ. MRI of bone marrow [PDF down- initiation of degenerative rotator cuff tears: an analy-
load]. American Roentgen Ray Society; 2005. sis of three hundred and sixty shoulders. J Bone Joint
http://www.arrs.org/shopARRS/products/pdf. Surg Am. 2010;92(5):1088–96.
cfm?theFile=s06p_sample.pdf. 34. Chansky HA, Iannotti JP. The vascularity of the rota-
17. Mirowitz SA. Hematopoietic bone marrow within tor cuff. Clin Sports Med. 1991;10(4):807–22.
the proximal humeral epiphysis in normal adults: 35. Matava MJ, Purcell DB, Rudzki JR. Partial-
investigation with MR imaging. Radiology. thickness rotator cuff tears. Am J Sports Med.
1993;188:689–93. 2005;33(9):1405–17.
18. Clark JM, Harryman DT. II: Tendons, ligaments, and 36. Fukuda H, Hamada K, Nakajima T, Yamada N,
capsule of the rotator cuff. Gross and microscopic Tomonaga A, Goto M. Partial-thickness tears
anatomy. J Bone Joint Surg. 1992;74-A:713–25. of the rotator cuff: a clinicopathological review
19. Erickson SJ, Cox IH, Hyde JS. Effect of tendon ori- based on 66 surgically verified cases. Int Orthop.
entation on MR imaging signal intensity: a manifes- 1996;20:257–265.30.
tation of the “magic angle” phenomenon. Radiology. 37. Fukuda H, Hamada K, Yamanaka K. Pathology and
1991;181(2):389–92. pathogenesis of bursal-side rotator cuff tears viewed
20. GuinelFilho H, Du J, Pak BC, et al. Quantitative from en bloc histologic sections. Clin Orthop Relat
characterization of the Achilles tendon in cadav- Res. 1990;254:75–80.31.
eric specimens: T1 and T2* measurements using 38. Fukuda H, Mikasa M, Ogawa K, et al. The partial
ultrashort-TE MRI at 3 T. Am J Roentgenol. thickness tear of the rotator cuff. Orthop Trans.
2009;192(3):W117–24. 1983;173:70–7.
21. Du J, Chiang AJ, Chung CB, Statum S, Znamirowski 39. Reilly P, Amis AA, Wallace AL, Emery
R, Takahashi A, et al. Orientational analysis of the RJ. Supraspinatus tears: propagation and strain
Achilles tendon and enthesis using an ultrashort alteration. J Shoulder Elb Surg. 2003;12:134–8.
echo time spectroscopic imaging sequence. Magn 40. Neer CS II. Anterior acromioplasty for the chronic
Reson Imaging. 2010;28:178–84. impingement syndrome in the shoulder: a prelimi-
22. Hodgson RJ, O’Connor PJ, Grainger nary report. J Bone Joint Surg Am. 1972;67:41–50.
AJ. Tendon and ligament imaging. Br J Radiol. 41. Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K,
2012;85(1016):1157–72. Tamai S. Tears of the rotator cuff of the shoulder
23. Buck F, Grehn H. Degeneration of the long biceps associated with pathological changes in the acro-
tendon: comparison of MRI with gross anatomy and mion: a study in cadavers. J Bone Joint Surg Am.
histology. Am J Roentgenol. 2009;193(5):1367–75. 1988;70:1224–30.
24. Fullerton GD, Rahal A. Collagen structure: the 42. Kolts I, Busch LC, Tomusk H, et al. Anatomical
molecular source of the tendon magic angle effect. composition of the anterior shoulder joint capsule. A
J Magn Reson Imaging. 2007;25:345–61. cadaver study on 12 glenohumeral joints. Ann Anat.
25. Hayes CW, Parellada JA. The magic angle effect 2001;183(1):53–9.
in musculoskeletal MR imaging. Top Magn Reson 43. Park YH, Lee JY, Moon SH, Mo JH, Yang BK, Hahn
Imaging. 1996;8:51–6. SH, Resnick D. MR arthrography of the labral cap-
26. Peto S, Gillis P, Henri VP. Structure and dynamics sular ligamentous complex in the shoulder: imaging
of water in tendon from NMR relaxation measure- variations and pitfalls. AJR. 2000;175:667–72.
ments. Biophys J. 1990;57(1):71–84. 44. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP
27. Al-Riyami AM, Lim BK, Peh WC. Variants and lesions of the shoulder. Arthroscopy. 1990;6:
pitfalls in MR imaging of shoulder injuries. Semin 274–9.
Musculoskelet Radiol. 2014;18:36–44. 45. Maffet MW, Gartsman GM, Moseley B. Superior
28. Peh WCG, Chan JHM. The magic angle phenom- labrum-biceps tendon complex lesions of the shoul-
enon in tendons: effect of varying the MR echo time. der. Am J Sports Med. 1995;23:93–8.
Br J Radiol. 1998;71:31–6. 46. Patten RM. Vacuum phenomenon: a potential pit-
29. Weinreb JH, Sheth C, Aposolakos J, et al. Tendon fall in the interpretation of gradient-recalled-echo
structure, disease, and imaging. Muscles Ligaments MR images of the shoulder. AJR. 1994;162(6):
Tendons J. 2014;4(1):66–73. 1383–6.
47. Stallenberg B, Madani A, Burny F, et al. The vacuum contrast material, and time on signal intensity. AJR.
phenomenon: a CT sign of nonunited fracture. AJR. 1994;163(3):621–3.
2001;176(5):1161–4. 65. Engel A. Magnetic resonance knee arthrography.
48. Dwyer AJ, Knop RH, Hoult DI. Frequency shift Enhanced contrast by gadolinium complex in the
artifacts in MR imaging. J Comput Assist Tomogr. rabbit and in humans. Acta Orthop Scand Suppl.
1985;9:16–8. 1990;240:1–57.
49. Rosen BR, Wedeen VJ, Brady TJ. Selective satu- 66. La Rocca Vieira R, Rybak LD, Recht M. Technical
ration NMR imaging. J Comput Assist Tomogr. update on magnetic resonance imaging of the
1984;8:813–8. shoulder. Magn Reson Imaging Clin N Am.
50. Guntern DV, Pfirmann CWA, Schmid MR, et al. 2012;20:149–61.
Articular cartilage lesions of the glenohumeral joint: 67. Masi JN, Newitt D, Sell CA, Daldrup-Link H,
diagnostic effectiveness of MR arthrography and Steinbach L, Majumdar S, et al. Optimization of
prevalence in patients with subacromial impinge- gadodiamide concentration for MR arthrography at
ment syndrome. Radiology. 2003;226:165–70. 3 T. AJR. 2005;184:1754–61.
51. Frahm J, Haase A, Hanicke W, et al. Chemical shift 68. Montgomery DD, Morrison WB, Schweitzer ME,
selective MR imaging using whole body magnet. Weishaupt D, Dougherty L. Effects of iodinated con-
Radiology. 1985;156:441–4. trast and field strength on gadolinium enhancement:
52. Haase A, frahm J, Hanicke W, et al. 1H NMR chemi- implications for direct MR arthrography. J Magn
cal shift selective (CHESS) imaging. Phys Med Biol. Reson Imaging. 2002;15:334–43.
1985;30:341–4. 69. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids
53. Osinski, et al. Magnetic resonance arthrography. to successful shoulder arthrography performed
Orthop Clin N Am. 2006;37:299–319. with a fluoroscopically guided anterior approach.
54. Steinbach LS, Palmer WE, Schweitzer ME. Special Radiographics. 2003;23:373–8.
focus session: MR arthrography. Radiographics. 70. Brown RR, Clarke DW, Daffner RH. Is a mixture of
2002;22:1223–46. gadolinium and iodinated contrast material safe dur-
55. Chandnani VP, Yeager TD, DeBerardino T, ing MR arthrography? AJR. 2000;175:1087–90.
Christensen K, Gagliardi JA, et al. Glenoid labral 71. Sanders TG, Tirman PF, Linares R, Feller JF,
tears: prospective evaluation with MR imaging, Richardson R. The glenolabral articular disruption
MR arthrography, and CT arthrography. AJR. lesion: MR arthrography with arthroscopic correla-
1993;161:1229–35. tion. AJR. 1999;172:171–5.
56. Beltran J, Bencardino J, Mellado J, Rosenberg 72. Masi JN, Newitt D, Sell CA, et al. Optimization of
ZS, Irish RD. MR arthrography of the shoulder: gadodiamide concentration for MR arthrography at
variants and pitfalls. Radiographics. 1997;17(6): 3 T. AJR. 2005;184:1754–61.
1403–12. 73. Lee MJ, Motamedi K, Chow K, et al. Gradient-
57. Shankman S, Bencardino J, Beltran J. Glenohumeral recalled echo sequences in direct shoulder MR
instability: evaluation using MR arthrography of the arthrography for evaluating the labrum. Skelet
shoulder. Skelet Radiol. 1999;28:365–82. Radiol. 2008;37(1):19–2.
58. Palmer WE, Brown JH, Rosenthal DJ. Labral liga- 74. Schreinemachers SA, van der Hulst VP, Willems WJ,
mentous complex of the shoulder: evaluation with Bipat S, van der Woude HJ. Detection of partial-
MR arthrography. Radiology. 1994;190:645–51. thickness supraspinatus tendon tears: is a single
59. Sethi PM, Kingston S, El Attrache N. Accuracy of direct MR arthrography series in ABER position as
anterior intra-articular injection of the glenohumeral accurate as conventional MR arthrography? Skelet
joint. Arthroscopy. 2005;21:77–80. Radiol. 2009;38:967–75.
60. Catalano OA, Manfredi R, Vanzulli A, et al. MR 75. Hodler J, Loredo RA, Longo C, Trudell D, Yu JS,
arthrography of the glenohumeral joint: modi- Resnick D. Assessment of articular cartilage thick-
fied posterior approach without imaging guidance. ness of the humeral head: MR–anatomic correlation
Radiology. 2007 Feb;242(2):550–4. in cadavers. AJR. 1995;165:615–20.
61. Porat S, Leupold JA, Burnett KR, Nottage 76. Pfirrmann CW, Zanetti M, Weishaupt D, Gerber
WM. Reliability of non-imaging-guided gleno- C, Hodler J. Subscapularis tendon tears: detec-
humeral joint injection through rotator interval tion and grading at MR arthrography. Radiology.
approach in patients undergoing diagnostic MR 1999;213:709–14.
arthrography. AJR. 2008;191(3):W96–9. 77. Waldt S, Burkart A, Imhoff AB, et al. Anterior shoul-
62. Zwar RB, Read JW, Noakes JB. Sonographically der instability: accuracy of MR arthrography in the
guided glenohumeral joint injection. AJR. classification of anteroinferior labroligamentous
2004;183:48–50. injuries. Radiology. 2005;237:578–83.
63. Mulligan ME. CT-guided shoulder arthrography at 78. Waldt S, Burkart A, Lange P, Imhoff P, Rummeny
the rotator cuff interval. AJR. 2008;191:58–61. EJ, Woertler K. Diagnostic performance of MR
64. Kopka L, Funke M, Fischer U, et al. MR arthrog- arthrography in the assessment of superior labral
raphy of the shoulder with gadopentetate dimeglu- anteroposterior lesions of the shoulder. AJR.
mine: influence of concentration, iodinated 2004;182:1271–8.
79. Giaconi JC, Link TM, Vail TP, et al. Morbidity of 95. Oh DK, Yoon YC, Kwon JW, Choi S-H, Jung JY,
direct MR arthrography. AJR. 2011;196:868–74. Bae S, et al. Comparison of indirect isotropic MR
80. Newberg AH, Munn CS, Robbins AH. Complications arthrography and conventional MR arthrography of
of arthrography. Radiology. 1985;155:605–6. labral lesions and rotator cuff tears: a prospective
81. Hugo PC 3rd, Newberg AH, Newman JS, Wetzner study. AJR. 2009;192:473–9.
SM. Complications of arthrography. Semin 96. Choo HJ, Lee SJ, Kim JH, et al. Delaminated tears
Musculoskelet Radiol. 1998;2:345–8. of the rotator cuff: prevalence, characteristics, and
82. Vahlensieck M, Sommer T, Textor J, et al. Indirect diagnostic accuracy using indirect MR arthrography.
MR arthrography: technique and applications. Eur AJR. 2015;204:360–6.
Radiol. 1998;8:232–5. 97. Fallahi F, Green N, Gadde S, et al. Indirect magnetic
83. Vahlensieck M, Lang P, Sommer T, Genant HK, resonance arthrography of the shoulder; a reliable
Schild HH. Indirect MR arthrography: techniques diagnostic tool for investigation of suspected labral
and applications. Semin Ultrasound CT MR. pathology. Skelet Radiol. 2013;42(9):1225–33.
1997;18:302–6. 98. Song KD, Kwon JW, Yoon YC, et al. Indirect MR
84. Vahlensieck M, Peterfy CG, Wischer T, et al. Indirect arthrographic findings of adhesive capsulitis. AJR.
MR arthrography: optimization and clinical applica- 2011;197(6):W1105–9.
tions. Radiology. 1996;200(1):249–54. 99. Murphy KP, Szopinski KT, Cohan RH, Mermillod
85. Drape JL, Thelen P, Gay-Depassier P, Silbermann O, B, Ellis JH. Occurrence of adverse reactions to
Benacerraf R. Intra-articular diffusion of Gd-DOTA gadolinium- based contrast material and manage-
after intravenous injection in the knee: MR imaging ment of patients at increased risk: a survey of the
evaluation. Radiology. 1993;188:227–34. American Society of Neuroradiology Fellowship
86. Winalski CS, Aliabadi P, Wright RJ, Shortkroff S, Directors. Acad Radiol. 1999;6:656–64.
Sledge CB, Weissman BN. Enhancement of joint 100. Magee T. Can isotropic fast gradient echo imag-
fluid with intravenously administered gadopentetate ing be substituted for conventional T1 weighted
dimeglumine: technique, rationale, and implications. sequences in shoulder MR arthrography at 3 Tesla? J
Radiology. 1993;187:179–85. Magn Reson Imaging. 2007;26:118–22.
87. Allmann KH, Schaefer O, Hauer M, et al. Indirect 101. Lee MJ, Motamedi K, Chow K, Seeger LL. Gradient-
MR arthrography of the unexercised glenohumeral recalled echo sequences in direct shoulder MR
joint in patients with rotator cuff tears. Investig arthrography for evaluating the labrum. Skelet
Radiol. 1999;34(6):435–40. Radiol. 2008;37:19–25.
88. Zoga AC, Schweitzer ME. Indirect magnetic reso- 102. Jung JY, Yoon YC, Choi SH. Three-dimensional
nance arthrography: applications in sports imaging. isotropic shoulder MR arthrography: compari-
Top Magn Reson Imaging. 2003;14:25–33. son with two-dimensional MR arthrography for
89. Kaura DR, Scweitzer ME, Weishaupt D, et al. the diagnosis of labral lesions at 3.0 T. Radiology.
Optimization of indirect arthrography of the knee 2009;250(2):498–50.
by application of external heat: initial experience. J 103. Gyftopoulos S, Yemin A, Mulholland T, et al. 3D
Magn Reson Imaging. 2005;22(6):810–2. MR osseous reconstructions of the shoulder using a
90. Weishaupt D, Schweitzer ME, Rawool NM, et al. gradient-echo based two-point Dixon reconstruction:
Indirect MR arthrography of the knee: effects of a feasibility study. Skelet Radiol. 2013;42:347–52.
low-intensity ultrasound on the diffusion rate of 104. Gyftopoulos S, Beltran LS, Yemin A, et al. Use of
intravenously administered Gd-DTPA in healthy 3D MR reconstructions in the evaluation of gle-
volunteers. Investig Radiol. 2001;36(8):493–9. noid bone loss: a clinical study. Skelet Radiol.
91. Yagci B, Manisali M, Yilmaz E, et al. Indirect MR 2014;43:213–8.
arthrography of the shoulder in detection of rotator 105. Zanetti M, Jost B, Hodler J, Gerber C. MR imaging
cuff ruptures. Eur Radiol. 2001;11:258–62. after rotator cuff repair: full-thickness defects and
92. Herold T, Bachthaler M, Hamer OW, Hente R, bursitis-like subacromial abnormalities in asymp-
Feuerbach S, Fellner C, et al. Indirect MR arthrog- tomatic subjects. Skelet Radiol. 2000;29(6):314–9.
raphy of the shoulder: use of abduction and exter- 106. Wolfgang GL. Surgical repair of tears of the rotator
nal rotation to detect full- and partial-thickness cuff of the shoulder. Factors influencing the result. J
tears of the supraspinatus tendon. Radiology. Bone Joint Surg Am. 1974;56(1):14–26.
2006;240:152–60. 107. Knudsen HB, Gelineck J, Sojbjerg JO, Olsen BS,
93. Van Dyck P, Gielen JL, Veryser J, et al. Tears of Johannsen HV, Sneppen O. Functional and magnetic
the supraspinatus tendon: assessment with indi- resonance imaging evaluation after single-tendon
rect magnetic resonance arthrography in 67 rotator cuff reconstruction. J Shoulder Elb Surg.
patients with arthroscopic correlation. Acta Radiol. 1999;8:242–6.
2009;50(9):1057–63. 108. Harryman DT, Mack LA, Wang KY, Jackins SE,
94. Jung JY, Yoon YC, Yi SK, Yoo J, Choe Richardson ML, Matsen FA III. Repairs of the rota-
BK. Comparison study of indirect MR arthrography tor cuff. Correlation of functional results with integ-
and direct MR arthrography of the shoulder. Skelet rity of the cuff. J Bone Joint Surg Am. 1991;73:
Radiol. 2009;38:659–67. 982–9.
109. Gazielly DF, Gleyze P, Montagnon C. Functional 126. Frazzini VI, Kagetsu NJ, Johnson CE, Destian
and anatomical results after rotator cuff repair. Clin S. Internally stabilized spine: optimal choice
Orthop Relat Res. 1994;304:43–53. of frequency-encoding gradient direction dur-
110. Galatz LM, Ball CM, Teefey SA, Middleton WD, ing MR imaging minimizes susceptibility artifact
Yamaguchi K. The outcome and repair integrity from titanium vertebral body screws. Radiology.
of completely arthroscopically repaired large and 1997;204:268–72.
massive rotator cuff tears. J Bone Joint Surg Am. 127. Naraghi AM, White LM. Magnetic resonance imag-
2004;86-A:219–24. ing of joint replacements. Semin Musculoskelet
111. Gerber C, Fuchs B, Hodler J. The results of repair of Radiol. 2006;10(1):98–106.
massive tears of the rotator cuff. J Bone Joint Surg 128. Lu W, Pauly KB, Gold GE, et al. SEMAC: slice
Am. 2000;82:505–15. encoding for metal artifact correction in MRI. Magn
112. Bohsali KI, Wirth MA, Rockwood CA Jr. Reson Med. 2009;62:66–76.
Complications of total shoulder arthroplasty. J Bone 129. Guermazi A, Miaux Y, Zaim S, Peterfy CG, White
Joint Surg Am. 2006;88:2279–92. D, Genant HK. Metallic artefacts in MR imaging:
113. Merolla G, Di Pietto F, Romano S, et al. Radiographic effects of main field orientation and strength. Clin
analysis of shoulder anatomical arthroplasty. Eur J Radiol. 2003;58:322–8.
Radiol. 2008;68:159–69. 130. Peh WC, Chan JH. Artifacts in musculoskeletal
114. Ha AS, Petscavage JM, Chew FS. Current concepts magnetic resonance imaging: identification and cor-
of shoulder arthroplasty for radiologists: part 2— rection. Skelet Radiol. 2001;30(4):179–91.
anatomic and reverse total shoulder replacement and 131. F DG, Santini F, Herzka DA, et al. Fat-suppression
nonprosthetic resurfacing. AJR. 2012;199:768–76. techniques for 3-T MR imaging of the musculoskel-
115. Ives EP, Nazarian LN, Parker L, et al. Subscapularis etal system. Radiographics. 2014;34(1):217–33.
tendon tears: a common sonographic finding in 132. Hayter CL, Koff MF, Shah P, et al. MRI after
symptomatic postarthroplasty shoulders. J Clin arthroplasty: comparison of MAVRIC and conven-
Ultrasound. 2013;41(3):129–33. tional fast spin-echo techniques. AJR. 2011;197(3):
116. Hennigan SP, Iannotti JP. Instability after prosthetic W405–1.
arthroplasty of the shoulder. Orthop Clin North Am. 133. Chen CA, Chen W, Goodman SB, et al. New MR
2001;52:649–59. imaging methods for metallic implants in the knee:
117. Neer CS 2nd, Watson KC, Stanton FJ. Recent expe- artifact correction and clinical impact. J Magn Reson
rience in total shoulder replacement. J Bone Joint Imaging. 2011;33:1121–7.
Surg. 1982;64(3):319–37. 134. Toms AP, Smith-Bateman C, Malcolm PN, et al.
118. Magee T, Shapiro M, Hewell G, et al. Complications Optimization of metal artefact reduction (MAR)
of rotator cuff surgery in which bioabsorbable sequences for MRI of total hip prostheses. Clin
anchors are used. AJR. 2003;181:1227–31. Radiol. 2010;65:447–52.
119. Nusselt T, Freche S, Klinger HM, et al. Intraosseous 135. Kolind SH, MacKay AL, Munk PL, et al. Quantitative
foreign body granuloma in rotator cuff repair with evaluation of metal artifact reduction techniques. J
bioabsorbable suture anchor. Arch OrthopTrauma Magn Reson Imaging. 2004;20:487–95.
Surg. 2010;130(8):1037–40. 136. Nwawka OK, Konin GP, Sneag DB, et al. Magnetic
120. Beltran LS, Bencardino JT, Steinbach resonance imaging of shoulder arthroplasty: review
LS. Postoperative MRI of the shoulder. J Magn article. HSS J. 2014 Oct;10(3):213–24.
Reson Imaging. 2014;40:1280–97. 137. Koch KM, Brau AC, Chen W, et al. Imaging near
121. Lee M, Kim S, Lee S, et al. Overcoming artifacts from metal with a MAVRIC-SEMAC hybrid. Magn
metallic orthopedic implants at high field-strength Reson Med. 2011;65:71–82.
MR imaging and multidetector CT. Radiographics. 138. Owen RS, Iannotti JP, Kneeland JB, Dalinka
2007;27:791–803. MK, Deren JA, Oleaga L. Shoulder after surgery:
122. Sperling JW, Potter HG, Craig EV, Flatow E, Warren MR imaging with surgical validation. Radiology.
RF. Magnetic resonance imaging of painful shoul- 1993;186:443–7.
der arthroplasty. J Shoulder Elb Surg. 2002;11: 139. Magee TH, Gaenslen ES, Seitz R, Hinson GA,
315–21. Wetzel LH. MR imaging of the shoulder after sur-
123. Eustace S, Goldberg R, Williamson D, et al. MR gery. AJR. 1997;168:925–8.
imaging of soft tissues adjacent to orthopaedic hard- 140. Stoller DW, Wolf EM. The shoulder. In: Stoller DW,
ware: techniques to minimize susceptibility artifact. editor. Magnetic resonance imaging in orthopae-
Clin Radiol. 1997;52:589–94. dics and sports medicine. 2nd ed. Philadelphia, PA:
124. Mohana-Borges AVR, Chung CB, Resnick D. MR Lippincott-Raven; 1997. p. 597–742.
imaging and MR arthrography of the postoperative 141. Zlatkin MB. MRI of the postoperative shoulder.
shoulder. Radiographics. 2004;24:69–85. Skelet Radiol. 2002;31:63–80.
125. Suh JS, Jeong EK, Shin KH, et al. Minimizing 142. Resnick D. Shoulder. In: Resnick D, Kang HS, edi-
artifacts caused by metallic implants at MR imag- tors. Internal derangements of joints: emphasis on
ing: experimental and clinical studies. AJR. MR imaging. Philadelphia, PA: Saunders; 1997.
1998;171:1207–13. p. 163–333.
143. Calvert PT, Packer NP, Stoker DJ, Bayley JI, Kessel 150. La Rocca Vieira R, Pakin SK, de Albuquerque
L. Arthrography of the shoulder after operative Cavalcanti CF, et al. Three-dimensional spin-
repair of the torn rotator cuff. J Bone Joint Surg Br. lock magnetic resonance imaging of the shoul-
1986;68:147–15. der joint at 3 T: initial experience. Skelet Radiol.
144. DeOrio JK, Cofield RH. Results of a second attempt 2007;36(12):1171–5.
at surgical repair of a failed initial rotator-cuff repair. 151. Bittersohl B, Miese FR, Dekkers C, et al. T2* map-
J Bone Joint Surg Am. 1984;66:563–56. ping and delayed gadolinium-enhanced magnetic
145. Duc SR, Mengiardi B, Pfirmann CW, et al. resonance imaging in cartilage (dGEMRIC) of gle-
Diagnostic performance of MR arthrography after nohumeral cartilage in asymptomatic volunteers at 3
rotator cuff repair. AJR. 2006;186:237–41. T. Eur Radiol. 2013;23(5):1367–74.
146. Wagner SC, Schweitzer ME, Morrison WB, Fenlin 152. Iwasaki K, Tafur M, Chang EY, Statum S, Biswas
JM, Bartolozzi AR. Shoulder instability: accuracy R, Tran B, Bae WC, Du J, Bydder GM, Chung
of MR imaging performed after surgery in depict- CB. High-resolution qualitative and quantitative
ing recurrent injury—initial findings. Radiology. magnetic resonance evaluation of the glenoid labrum.
2002;222:196–203. J Comput Assist Tomogr. 2015;39(6):936–44.
147. Jazrawi LM, Alaia MJ, Chang G, et al. Advances in 153. Chang G, Sherman O, Madelin G, et al. MR
magnetic resonance imaging of articular cartilage. J imaging assessment of articular cartilage repair
Am Acad Orthop Surg. 2011;19(7):420–9. procedures. Magn Reson Imaging Clin N Am.
148. Wiener E, Hodler J, Pfirrmann CW. Delayed 2011;19(2):323–37.
gadolinium- enhanced MRI of cartilage (dGEM- 154. Keenan KE, Besier TF, Pauly JM, et al. Prediction
RIC) of cadaveric shoulders: comparison of con- of glycosaminoglycan content in human carti-
trast dynamics in hyaline and fibrous cartilage after lage by age, T1ρ and T2 MRI. Osteoarthr Cartil.
intra-articular gadolinium injection. Acta Radiol. 2011;19(2):171–9.
2009;50(1):86–92. 155. Lee SY, Park HJ, Kwon HJ, et al. T2 relaxation times
149. Maizlin ZV, Clement JJ, Patola WB, et al. T2 map- of the glenohumeral joint at 3.0 T MRI in patients
ping of articular cartilage of glenohumeral joint with with and without primary and secondary osteoarthri-
routine MRI correlation–initial experience. HSS J. tis. Acta Radiol. 2015;56(11):1388–95.
2009;5(1):61–6.
Sonographic Evaluation
of the Shoulder 3
Avner Yemin and Ronald S. Adler
3.1 Introduction impingement syndromes [4]. In addition to gray-

scale imaging the use of color and/or power
Diagnostic shoulder sonography has been well Doppler imaging can be utilized to detect hyper-
documented and established as an accurate tool emia during the examination, which has been
for evaluation of shoulder pathology. In fact a associated with symptomatic tendinopathy,
meta-analysis study has shown the sensitivity and inflammation, and repair states. In this chapter
specificity of diagnostic ultrasound to be compa- we discuss the approach to performing shoulder
rable to those of conventional MRI [1]. However, sonography, relevant anatomy, and relevant inter-
the diagnostic accuracy of shoulder sonography pretation pitfalls.
has been shown to depend on the experience and
skill of the sonographer [2]. Although shoulder
sonography may be time consuming for the nov- 3.2 Sonographic Shoulder
ice, with experience, a better understanding of Anatomy
the sonographic anatomy, and the use of a stan-
dardized protocol, the examination can be per- There are four muscles and tendons, which make
formed quickly [3]. In addition to its short up the rotator cuff: the supraspinatus, the infra-
acquisition time, shoulder sonography has a mar- spinatus, the subscapularis, and the teres minor.
ketable advantage of being inexpensive when Normal muscle on sonography appears as a struc-
compared to MRI. However, the most distinct ture made up of a hypoechoic background with
advantage is the ability to assess for pathology in superimposition of multiple curvilinear and
real time both at static and dynamic states. sometimes punctate echogenic areas correspond-
Provocative maneuvers can be performed to ing to the perimysial connective tissue (Figs. 3.1
assess for pathology amenable to be accentuated and 3.2).
by positional maneuvers, for example, The four tendons of the rotator cuff each has
unique bony attachments, which are used as
landmarks to assist in identification of each ten-
A. Yemin (*)
Envision Physician Services—Radiology Associates don. The supraspinatus tendon inserts onto the
of Hollywood, Memorial Healthcare System, superior facet and superior half of the middle
Hollywood, FL, USA facet of the greater tuberosity. The infraspina-
e-mail: avner.yemin@shcr.com tus tendon also inserts along the middle facet of
R. S. Adler the greater tuberosity, just posterior to the
Department of Radiology, NYU Langone Health, supraspinatus tendon and with some overlap of
New York, NY, USA
e-mail: Ronald.Adler@nyulangone.org the fibers in a junctional zone. The teres minor

56 A. Yemin and R. S. Adler
a b c
Fig. 3.1 Muscle imaging—supraspinatus patient positioning (a); short-axis sonographic image (b); MRI correlate (c);
supraspinatus (SS); deltoid (D)
a b c
Fig. 3.2 Muscle imaging—infraspinatus patient positioning (a); short-axis sonographic image (b); MRI correlate (c);
infraspinatus (IS)
tendon is positioned inferior to the infraspina-

tus tendon and thus inserts along the inferior
facet of the greater tuberosity [5]. The subscap-
ularis tendon inserts onto the lesser tuberosity
of the humerus.
As demonstrated in Fig. 3.3, deep to the sub-
deltoid bursa is the supraspinatus tendon, which
is a convex echogenic structure with well-
demarcated convex margin that tapers distally as
it inserts on the footprint. It is crucial to be able to
distinguish the thin hypoechoic area, which is
often seen as the tendon fiber insert, from a
Fig. 3.3 Supraspinatus long-axis view—supraspinatus
partial-thickness tear or tendinosis.
tendon (SST): deltoid (D); peri-bursal fat (PBF); subdel-
The long head of the biceps tendon has both toid bursa (arrow); convex tendon (c); greater tuberosity
intra- and extra-articular components. It (GT); humeral head (HH)
3 Sonographic Evaluation of the Shoulder 57
a b c
d e f
Fig. 3.4 Biceps tendon—short-axis patient positioning sonographic image (e); MR correlate of long axis (f);
(a); short-axis sonographic image (b); MR correlate of biceps tendon (*) Greater tuberosity (GT); lesser tuberos-
short axis (c); long-axis patient positioning (d); long-axis ity (LT); Biceps groove (curved line)
o riginates from the superior margin of the gle- Additionally certain positions are used to
noid and courses anterolaterally through the rota- optimally view the different tendons creating

tor interval and extends inferiorly between the oblique views. Therefore utilizing the standard
greater and lesser tuberosities in the bicipital anatomic planes for sonography can create con-
groove (a.k.a. intertubercular groove), where it is fusion. As such it is convenient to discuss ten-
considered extra-articular (Fig. 3.4). dons in terms of long axis or short axis. The
The subacromial-subdeltoid bursa is a syno- long-axis view assesses the tendon in length as it
vial lined space that lies deep to the deltoid and attaches on the footprint and the short-axis view
acromion. As demonstrated in Fig. 3.3, there is is perpendicular to that (Fig. 3.5).
a distinct peri-bursal fat stripe deep to the del-
toid. The subdeltoid bursa is interposed between
the fat stripe and the superficial margin of the 3.4 Anisotropy
tendon and is generally seen as a thin
hypoechoic line, usually less than 2 mm in The difficulty with scanning the shoulder in par-
thickness in normal individuals [3]. This can be ticular is that the structures are curvilinear
distended in the setting of subacromial/subdel- which leads to issues with anisotropy so that
toid bursitis. when you are scanning initially the most echo-
genic portion is going to be that portion of the
tendon which is perpendicular to the transducer
3.3 Nomenclature scan plane. However, if the adjacent tendon
fibers are angled, and not perpendicular to the
When performing ultrasound the orientation of transducer, the tendon will appear progressively
the transducer is positioned in multiple different hypoechoic due to anisotropy, which can easily
planes as we attempt to best view the tendons. be mistaken for tendinosis or tear. This problem
Fig. 3.5 Tendon orientation—long-axis (a) and short-axis (b) views
Fig. 3.6 Rocking the transducer to eliminate anisotropic effect at footprint
is very common, as an angle of as little as 2–3° This anisotropy is commonly seen at the tendon
has been shown to produce anisotropy [6]. footprint where the tendon fibers are curvilinear
Hence, when scanning, it is critical to reorient as they attach to bone. Rocking of the trans-
the transducer so that it is perpendicular to the ducer back and forth along the long axis can be
tendon fibers being evaluated to exclude anisot- used to show if there is a true tear or just anisot-
ropy for the hypoechoic nature of the tendon. ropy (Fig. 3.6).
Table 3.1 Standardized shoulder sonography protocol

Biceps Short axis—3 images → Long axis—2 images → proximal and distal
proximal to distal
AC joint 1 image across joint
Subscapularis Short axis—3 images → near Long axis—2 images → proximal and distal
coracoid, mid, and distal
Muscle Short axis only 1 image each
– Infraspinatus
– Teres minor
– Supraspinatus
Supraspinatus/infraspinatus Short axis—3 Long axis—3 images → lateral (infraspinatus), mid
(Crass or modified Crass) images → proximal to distal (junctional zone), medial (near rotator interval)
3.5 Technique Table 3.2 Biceps tendon guidelines

Technique Findings
Several different guidelines have been estab- Short – One image above – Tendon is an
lished for performance of shoulder sonography, axis groove echogenic ellipse in
first – At least 2 below the bicipital groove
some of which advocate that the sonographer is – Demonstrates fluid/
positioned in front of the patient and others advo- synovitis
cate scanning from behind the patient [6–8]. We Long – Turn transducer 90° Tendon is linear and
have found approaching the patient from the axis – To avoid anisotropy tilt fibrillar
transducer to
front to be most convenient and for the purposes
maximize echogenicity
of the chapter will be describing this technique.
We advise having the patient sitting down on a
chair, which can revolve to ease the transitions forearm supinated. This position places the bicip-
between steps. In addition patient positioning ital groove anteriorly. In short axis you should
should be optimized to allow for the most ergo- see the long head of the biceps tendon within the
nomically comfortable scanning position for the bicipital groove. By turning the transducer 90°
examiner. you can assess the length of the long head of the
The two most important aspect of shoulder biceps tendon as an echogenic fibrillar structure.
sonography is to maintain a standardized proto- In certain situations you may need to rock the
col with a systematic approach and second is to transducer back and forth in order to make the
properly position the arm to optimally look at all transducer as parallel to the biceps tendon as
the shoulder structures (Table 3.1). We advise possible.
looking at the anterior structures first followed by
posterior structures and lastly evaluating the
supraspinatus tendon, as the positioning is usu- 3.6.2 tep 2: Evaluating
S
ally the most uncomfortable for the patient, thus the Acromioclavicular Joint
leaving the worst for last. (Fig. 3.7)
Start by palpating the acromioclavicular joint and

3.6 Step-by-Step Guideline placing the transducer in long axis along the top
of the joint. You will be able to see the distal clav-
3.6.1 tep 1: Evaluating the Long
S icle and acromion and the interposed joint cap-
Head of the Biceps Tendon sule/fibrocartilage disc. When assessing the
(Fig. 3.4; Table 3.2) acromioclavicular joint look for joint capsular
distension, osseous irregularities, joint widening,
The patient should be seated with the arm at their or a step-off between the clavicle and acromial
side with the elbow in 90-degree flexion and the process. If there is suspicion for a widened joint
a b
Fig. 3.7 Acromioclavicular joint imaging—patient positioning (a); sonographic image (b); joint capsule (J)
Fig. 3.8 Subacromial impingement dynamic imaging—patient positioning with progressive increase of arm abduction
while imaging
or articular step-off dynamic maneuvers such as ment (Fig. 3.8). This is done by placing the
internally and externally rotating the patient’s transducer just lateral to the acromial process
arm actively can be utilized. and moving the patient’s arm through a range of
Additionally dynamic maneuvers can be abduction and adduction while imaging.
performed to assess for subacromial impinge- Findings of subacromial impingement include
a b c
d e f
Fig. 3.9 Subscapularis tendon—short-axis patient posi- positioning (d); long-axis sonographic image (e); MR cor-
tioning (a); short-axis sonographic image (b); MR corre- relate of long axis (f); supraspinatus tendon (SST)
late of short axis—multipennate (c); long-axis patient
snapping of the bursal tissue and abnormal Table 3.3 Subscapularis tendon
upward migration of the humeral head with Technique Findings
respect to the acromion [8]. Long- Externally rotate – Tendon footprint is a
axis forearm with curvilinear structure
image transducer in tapering down to the bony
first fixed position attachment
3.6.3 tep 3: Subscapularis Tendon
S – Look for humeral anatomic
(Fig. 3.9; Table 3.3) neck and beginning of
articular cartilage
The patient’s arm should be placed in external Short Turn transducer Tendon is multipennate
axis 90°
rotation in order to bring the subscapularis away
from the coracoid process which otherwise would
partially impede visualization due to dense shad- tendon length and is noted to be with the trans-
owing. External rotation will therefore expose ducer in what would conventionally be a
the subscapularis tendon and place it in some transverse orientation (anatomic axial plane).

degree of hyperextension. The footprint of the Hence, by turning the transducer 90° (transducer
subscapularis tendon will be seen as a curvilinear in the sagittal plane), we will be assessing the
structure tapering down to the bony attachment. tendon in short axis. In this plane, the long head
Assessment of the subscapularis footprint is of the biceps tendon may appear as a separate
achieved by looking at the anatomic neck and the round hyperechoic structure just superior to the
beginning of the humeral head articular cartilage subscapularis tendon. Given the multipennate
(black line). As discussed in the nomenclature structural arrangement of the subscapularis ten-
section, the long-axis view is in respect to the don, multiple round echogenic areas may be
seen. This is a key concept, as we do not want to sion in the Crass position [9] (Fig. 3.10). The
misinterpret these multiple tendon slips that Crass position entails placing the arm behind the
eventually come together to form the single con- back with the palm pointed out. In short axis you
joined tendon as it inserts on the lesser tuberosity, will see the biceps tendon medially, and the
for a tear. supraspinatus laterally. Reorienting the trans-
ducer 90° will demonstrate the supraspinatus ten-
don in long axis as a convex echogenic tendon
3.6.4 tep 4: Supraspinatus/
S with tapering as it extends to the footprint. The
Infraspinatus Tendons second approach is a modified Crass with the dif-
and Rotator Interval (Table 3.4) ference being that the hand is placed as if it was
in the back pocket [10] (Fig. 3.11). The advan-
There are two different ways of looking at the tage of this is less external rotation which allows
supraspinatus tendon, each with relative advan- for better visualization of the rotator interval.
tages. The first provides for greater hyperexten- Again the biceps tendon will be located medially
Table 3.4 Supraspinatus and infraspinatus tendon imaging

Technique Findings
Crass – Internal rotation, Short axis: biceps tendon medially and the supraspinatus laterally
hyperextension Long axis: supraspinatus tendon in long axis → convex echogenic tendon
– Arm behind back, palm with tapering as it extends to the footprint
out, fingers toward scapula
Modified Arm behind back with hand Short axis: biceps tendon medially, then the rotator interval, then the
Crass in “back pocket” supraspinatus laterally
Long axis: supraspinatus tendon in long axis → may see less of the tendon
a b c
d e f
Fig. 3.10 Crass position: supraspinatus/infraspinatus axis (c); long-axis patient positioning (d); long-axis sono-
and rotator interval—short-axis patient positioning (a); graphic image (e); MR correlate of long axis (f); supraspi-
short-axis sonographic image (b); MR correlate of short natus tendon (SST); deltoid (D)
a b
c d
Fig. 3.11 Modified Crass supraspinatus/infraspinatus tioning (b); long-axis sonographic image (d); supraspina-
and rotator interval— short-axis patient positioning (a); tus (SST); biceps tendon (BT); subscapularis (SSC)
short-axis sonographic image (c); long-axis patient posi-
and the rotator interval and supraspinatus tendon patients, especially in cases of adhesive
laterally. The disadvantage is that you tend to not capsulitis.
see as much of the tendon while the arm is in It is important to note, particularly when scan-
hyperextension. However, studies demonstrate ning the rotator cuff in short axis, that there is a
no significant difference in the overall accuracy transitional zone where there is a blending of
when comparing the two techniques [11]. If the both infraspinatus and supraspinatus fibers
patient can tolerate both positions we believe that (Fig. 3.12). As a rule of thumb from the level of
there is added value in performing both with opti- the rotator interval approximately 2 cm from its
mal visualization of both the supraspinatus ten- anterior margin will be supraspinatus tendon,
don and the rotator interval in the modified Crass then there is a junctional zone with mixed supra-
and Crass, respectively. Of note the modified spinatus and infraspinatus fibers, and more poste-
Crass may be more comfortable for certain riorly there will be the infraspinatus tendon.
a b
c d
Fig. 3.12 Rotator cuff—short-axis sonographic image don (SST); infraspinatus tendon (IST): In short axis gen-
(a); short-axis MRI correlate (b); long-axis sonographic erally 2 cm lateral to the rotator interval will be the
image (c); long-axis MRI correlate (d); supraspinatus ten- supraspinatus tendon
3.6.5 tep 5: Muscle Evaluation—

S 3.6.6 tep 6: Muscle Evaluation—
S
Supraspinatus (Fig. 3.1) Infraspinatus and Teres Minor
(Fig. 3.2)
Muscle evaluation is crucial as atrophy and fatty
infiltration have been shown to be associated Position the transducer more posteriorly and cau-
with failed rotator cuff repairs and poor clinical dally below the level of the scapular spine you
outcomes [12]. Evaluation of the muscle is a will find the infraspinatus muscle in the infraspi-
fairly simple portion of the exam. Initially place natus fossa. Moving the transducer slightly cau-
the transducer in a sagittal orientation superior to dally you will see the teres minor muscle.
the spine of the scapula to evaluate the supraspi- Evaluation of the subscapularis muscle is lim-
natus muscle in the suprascapular fossa with the ited due to the lack of a proper acoustic window,
trapezius muscle overlying it. Again note that as the muscle lies deep to the pectoralis and tho-
normal muscle is hypoechoic and within that rax anteriorly, and the scapula posteriorly.
hypoechoic background curvilinear echogenic Accounting for these limitations the muscle tis-
areas are seen, corresponding to the perimysial sue interposed between the tendon fascicles can
connective tissue. be imaged along the course of the multipennate
tendon insertional fibers and, as described earlier, 4. Minagawa H, Itoi E, Konno N, Kido T, Sano A,
they should not be mistaken for a tendon tear. Uramaya M, et al. Humeral attachment of the supra-
spinatus and infraspinatus tendons: an anatomic study.
Arthroscopy. 1998;14(3):302–6.
5. Crass JR, van de Vegte GL, Harkavy LA. Tendon
3.7 Conclusion echogenicity: ex vivo study. Radiology.
1988;167(2):499–501.
6. Finnoff JT, Smith J, Peck ER. Ultrasonography
Shoulder sonography has been proven to be a of the shoulder. Phys Med Rehabil Clin N Am.
sensitive and specific diagnostic tool in assessing 2010;21:481–507.
shoulder pathology. With the implementation of a 7. Moosikasuwan JB, Miller TT, Burke BJ. Rotator
standardized protocol, such as the one outlined in cuff tears: clinical, radiographic, and US findings.
Radiographics. 2005;25:1591–607.
this chapter, accompanied by appropriate knowl- 8. Bureau NJ, Beauchamp M, Cardinal E, Brassard
edge of the sonographic shoulder anatomy we P. Dynamic sonography evaluation of shoulder
believe that it can be utilized as a powerful addi- impingement syndrome. AJR Am J Roentgenol.
tion to the radiologist’s armamentarium. 2006;187(1):216–20.
9. Crass JR, Craig EV, Feinberg SB. The hyperextended
internal rotation view in rotator cuff ultrasonography.
J Clin Ultrasound. 1987;15(6):416–20.
References 10. Ferri M, Finlay K, Popowich T, Stamp G, Schuringa P,
Friedman L. Sonography of full-thickness supraspina-
1. De Jesus JO, Parker L, Frangos AJ, Nazarian tus tears: comparison of patient positioning technique
LN. Accuracy of MRI, MR arthrography, and ultra- with surgical correlation. AJR Am J Roentgenol.
sound in the diagnosis of rotator cuff tears: a meta- 2005;184(1):180–4.
analysis. AJR Am J Roentgenol. 2009;192(6):1701–7. 11. Shah NP, Miller TT, Stock H, Adler RS. Sonography
2. Le Corroller T, Cohen M, Aswad R, Pauly V, of supraspinatus tendon abnormalities in the neutral
Champsaur P. Sonography of the painful shoulder: versus crass and modified crass positions a prospec-
role of the operator’s experience. Skelet Radiol. tive study. J Ultrasound Med. 2012;31(8):1203–8.
2008;37(11):979–86. 12. Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty
3. Jacobson JA. Shoulder US: anatomy, technique, and infiltration and rotator cuff atrophy. J Am Acad
scanning pitfalls. Radiology. 2011;260(1):6–16. Orthop Surg. 2013;21(10):613–23.
Image-Guided Procedures
of the Shoulder 4
Ogonna Kenechi Nwawka, Shefali Kothary,
and Theodore T. Miller
4.1 Introduction available, especially in teenagers and young

adults [1]. Multiple studies have demonstrated
Shoulder pain is a common complaint in the adult US as effective in image guidance for shoulder
patient population, caused by a wide variety of MR arthrography [2–4], with similar success
conditions affecting the osseous and soft-tissue rates when compared to fluoroscopic guidance
structures in the shoulder. Image-guided shoulder [5, 6]. When performing US-guided procedures,
interventions are important for both diagnosis a high-resolution, high-frequency transducer
and treatment of conditions that affect the shoul- should be used. Typically at our institution, we
der. Image-guided interventions can be per- use a 12–15 MHz linear transducer for proce-
formed with different imaging modalities dures around the shoulder.
including ultrasound (US), fluoroscopy, com- Fluoroscopy is also commonly used to guide
puted tomography (CT), and magnetic resonance therapeutic injections, and during joint aspiration
imaging (MRI), depending on the anatomy, dis- and instillation of intra-articular contrast for
ease process, and type of intervention. This chap- arthrography. The glenohumeral joint is easily
ter provides technical guidelines for performing accessed under fluoroscopic guidance, with well-
image-guided shoulder interventions, concentrat- established technique [7]. Although CT and MRI
ing on sonographic guidance. are typically reserved for performing biopsies
around the shoulder, there is literature supporting
their use in guidance for arthrography [8–10],
4.2 General Considerations particularly when sonographic or fluoroscopic
guidance is not available.
4.2.1 Imaging Techniques
Image-guided shoulder interventions are most 4.2.2 Procedure

commonly performed under US or fluoroscopy.
The real-time nature of US imaging and lack of As part of the pre-procedure preparation, the site
ionizing radiation are advantageous, and thus of needle puncture should be marked with indel-
image guidance via US is recommended when ible ink under image guidance.
The needle gauge and length are selected
O. K. Nwawka ∙ S. Kothary ∙ T. T. Miller (*) based on the procedure to be performed and the
Division of Ultrasound, Department of Radiology and patient’s body habitus. In an average-size per-
Imaging, Hospital for Special Surgery, Weill Medical son, all injections around the shoulder can be
College of Cornell University, New York, NY, USA performed with 22–25-gauge 1.5–3.5 in. n eedles.
e-mail: nwawkao@hss.edu; millertt@hss.edu

68 O. K. Nwawka et al.
Aspirations are usually performed with an short axis) to the transducer (Fig. 4.1). When
18-gauge 1.5 or 3.5 in. needle depending on inserting the needle in plane, it is important to
patient’s body habitus and depth of the target. visualize the entire length of the needle at all
For optimal needle visualization during US pro- times and to visualize the needle bevel in order
cedures, the needle should be oriented as close to to avoid crosscutting error and misplacement of
perpendicular to the orientation of the US beam the needle tip [11] (Figs. 4.2 and 4.3). Rotating
as possible. The needle may be advanced in or gently agitating the needle may help in visual-
plane (i.e., longitudinal) or out of plane (i.e., ization of the needle tip.
a b
Fig. 4.1 Needle placement in plane (a) and out of plane (b) to the transducer
a b
Fig. 4.2 In-plane needle placement with correct technique. The needle is in line with the transducer (a), and the entire
length of the needle is seen on the US image, including the echogenic tip (b, arrow)
a b
Fig. 4.3 In-plane needle placement with crosscutting error. The needle is not in line with the transducer (a), and the
entire length of the needle is not visualized (b). This can result in misplacement of the needle tip
4 Image-Guided Procedures of the Shoulder 69
To maintain sterile technique during the pro- space, the needle should be within the joint. You
cedure, the transducer should be prepped or cov- may perform a test injection with anesthetic,
ered with a sterile sheath, following manufacturer e.g., 1% lidocaine to confirm intra-articular
recommendations. positioning of the needle tip. The test injectate
should freely flow into the joint space without
resistance; if not, the needle tip may be buried
4.3 Glenohumeral Joint within the articular cartilage or in an extra-artic-
ular position and should be repositioned until
4.3.1 Ultrasound intra-articular flow is confirmed. Subsequently,
upon injection of the desired mixture, fluid
An anterior or posterior approach can be used, should smoothly distend the posterior glenohu-
though the injection is typically performed via a meral recess (Fig. 4.5b).
posterior approach [11], with the patient in a lat- For the anterior US approach, the patient is
eral decubitus position and with the arm placed supine with the arm by the side in external
extended at the shoulder and bent at the elbow rotation. The injection is performed at the level of
(Fig. 4.4). A 25-gauge 1.5 in. needle or a the coracoid, inserting the needle in a lateral-to-
22-gauge 3.5 in. needle should be used for the medial or medial-to lateral approach [4, 5]. As
injection, depending on the patient’s body habi- with the posterior approach, the target is the
tus. The needle is inserted in plane to the trans- humeral head cartilage or fluid within the joint
ducer via a lateral-to-medial approach (Fig. 4.4). space (Fig. 4.6).
The target for the injection should be the articu-
lar cartilage over the humeral head or the poste-
rior recess of the glenohumeral joint (Fig. 4.5a). a
If present, a joint effusion within the posterior
recess of the glenohumeral joint is a good target.
Once the needle contacts the humeral head
articular cartilage or the fluid within the joint
Fig. 4.5 (a and b) US images demonstrate needle place-

ment (arrowhead) within the posterior glenohumeral joint
prior to injection. Posteriorly, the glenohumeral joint is
located deep to the infraspinatus tendon (arrows). Prior to
injection, the posterior glenohumeral joint recess is col-
lapsed (a, block arrow). During injection, there is disten-
Fig. 4.4 Glenohumeral joint injection: Patient position- tion of the posterior glenohumeral recess with injectate
ing and needle placement for posterior approach (asterisk). H humeral head
4.3.2 Fluoroscopy may be used to assure proper arm positioning

during the procedure. The goal is for the humeral
When performing a glenohumeral joint injection head to overlap the posterior glenoid rim, pro-
under fluoroscopic guidance, an anterior ducing an ellipse (Fig. 4.8). The image intensifier
approach is typically used. The patient is placed (II) can also be slightly obliqued to obtain this
on the fluoroscopy table in a supine position, appearance. The recommended target for gleno-
with the arm externally rotated and the forearm humeral joint injection varies, with some advo-
and wrist in supination (Fig. 4.7). A sand bag cating the upper third of the ellipse and others
advocating the middle or lower third [7, 12, 13].
All of these recommended positions fall just lat-
eral to the medial cortex of the humeral head. A
22-gauge 3.5 in. needle is typically used for
injection, though a 25-gauge 1.5 in. needle may
also be sufficient depending on the patient’s body
Fig. 4.6 Anterior approach for glenohumeral injection

under US. Simulated needle trajectory for an anterior gle-
nohumeral injection (dotted line). H humeral head, G
Glenoid, * Anterior joint recess. Arrows—subscapularis Fig. 4.7 Glenohumeral joint injection: Patient
tendon positioning
Fig. 4.8 Needle placement is recommended just lateral to the medial cortex of the humeral head, within the ellipse
formed by the overlap of the glenoid and humeral head
Fig. 4.9 Fluoroscopic image after intra-articular injec-

tion of contrast demonstrates contrast material in the joint Fig. 4.10 Fluoroscopic image after intra-articular injec-
space (arrows) and within the expected confines of the tion of contrast reveals contrast within the joint capsule
joint capsule (dotted line) and also extravasating into the subacromial-subdeltoid
bursa (arrows), diagnostic of a rotator cuff tear. Suture
anchors from prior rotator cuff repair are noted
habitus. Under intermittent fluoroscopy to check or instability, as inadvertent extra-articular con-

needle positioning, the needle should be advanced trast extravasation posteriorly will not confound
until contact is made with the bony surface of the anterior pathology [14, 15]. The patient should be
humeral head. If the needle is advanced into the placed on the fluoroscopy table in a prone posi-
glenohumeral joint space, any further manipulation, with a foam pad placed under the ipsilateral
tion should be gentle in order to avoid damage to shoulder and thorax to oblique the shoulder and
the articular cartilage and labrum [14]. Once the provide an en face view of the glenohumeral
needle appears to be in a good position, a test joint. The patient’s arm should be in a neutral or
injection should be performed with a low osmo- internally rotated position. The needle target is
lar contrast material to confirm intra-articular just lateral to the medial cortex of the humeral
positioning of the needle. An intra-articular injec- head, similar to the anterior approach.
tion should demonstrate contrast flowing freely
away from the needle into the glenohumeral joint
or within the expected confines of the joint cap- 4.4 Glenohumeral Joint
sule (Fig. 4.9). Lack of contrast spread may sug- Aspiration
gest injection into overlying muscle or tendon.
Once the appropriate needle position is con- Glenohumeral joint aspiration is usually per-
firmed, the desired intra-articular medium may formed to obtain a sample of joint fluid for analy-
be instilled. During arthrography, the presence of sis when infection is suspected, usually in the
a rotator cuff tear may be diagnosed by prosthetic shoulder. The technique employed for
extra-articular extension of contrast into the over- an US-guided glenohumeral joint aspiration is
lying subacromial-subdeltoid bursa (Fig. 4.10). similar to that used in injection, and either an
Glenohumeral joint injections can also be per- anterior or a posterior approach may be used. The
formed under fluoroscopic guidance using a pos- patient positioning is the same, and joint fluid is
terior approach. The positioning is advocated in the desired target. Different from a joint injec-
patients with suspected anterior labral pathology tion, no test injection with anesthetic should be
a b
Fig. 4.11 (a) Fluoroscopic image demonstrate oblique possible, the target should be the metallic humeral head
needle trajectory (arrow) for glenohumeral joint aspira- component. During contrast injection (b), there is opacifi-
tion/injection in a patient with a shoulder implant. When cation of the joint pseudocapsule (*)
performed prior to aspiration of native joint fluid cuff. The bursa runs both anteroposteriorly and
to avoid inaccurate cell count analysis and poten- mediolaterally, and extends beyond the rotator
tial bactericide. If there is no visible joint fluid or cuff insertion. Therefore, the SASD bursa can be
no fluid can be aspirated on initial attempt, a accessed via an anterior, lateral, or posterior
lavage may be performed by injecting and re- approach [16] with the patient in a supine, lateral
aspirating sterile non-bacteriostatic and decubitus, or seated position.
preservative-free saline to obtain a fluid sample A 25-gauge 1.5 in. needle or a 22-gauge 3.5 in.
for analysis. A large-bore needle (e.g., 18-gauge) needle can be used for injection, depending on
is typically used for aspiration. the patient’s body habitus. 2–3 mL of an anes-
Glenohumeral joint aspiration under fluoros- thetic and cortisone mixture is typically used for
copy is also similar to the technique used in a therapeutic injection [16], although up to 10 mL
injection. If aspiration is being performed in a can comfortably be injected into the bursa. For a
prosthetic joint, the target should be the humeral lateral approach, the needle should be inserted in
head component. An oblique needle trajectory is plane to the transducer via a lateral-to-medial
recommended for better needle visualization approach (Fig. 4.12). The hypoechoic bursa
over a metallic target like a prosthetic humeral between the echogenic peribursal fat should be
component (Fig. 4.11). As with US, aspiration of targeted (Fig. 4.13a). Of note, fluid within the
native joint fluid should be attempted first before bursa is an excellent target if present. When hold-
the instillation of intra-articular contrast. ing the transducer, it is important not to use too
much pressure as this can efface fluid within the
SASD bursa. Once the needle appears to be in a
4.5 Subacromial-Subdeltoid good position, perform a test injection with anes-
Bursa thetic to confirm that the needle tip is within the
bursa. If there is no visible fluid within the bursa,
The subacromial-subdeltoid (SASD) bursa is insert the needle between the peribursal fat stripes
located deep to the acromioclavicular joint and and inject anesthetic to create a visible plane.
extends like a saddle superficially over the rotator There should be smooth linear distention of the
SASD over the rotator cuff tendon, and fluid will

extend lateral to the rotator cuff insertion
(Fig. 4.13b).
An 18- or 20-gauge needle can be used for
aspiration of the SASD bursa. The technique is
the same as described above, with fluid as the tar-
get. If no fluid is present, a lavage can be per-
formed to obtain a bursal fluid sample, using
sterile saline.
4.6 Biceps Tendon Sheath
The long head of the biceps tendon (LHBT) orig-

inates at the supraglenoid tubercle of the scapula
within the glenohumeral joint, extends through
Fig. 4.12 Patient positioning and needle placement for
SASD bursal injection
the rotator interval, and courses distally within
the bicipital groove between the greater and
lesser tuberosities of the humerus. The extra-
articular LHBT sits within a tendon sheath, com-
a posed of a synovial membrane, as it travels within
the bicipital groove. The tendon sheath, which
communicates with the glenohumeral joint, can
contain a small amount of physiologic fluid even
in the absence of pathology. The proximal biceps
is well seen with US at and distal to the bicipital
groove, and US is the preferred method for
image-guided injection.
The patient is positioned supine with the arm
by the side in external rotation (Fig. 4.14). This
b will position the bicipital groove at the 12:00
position, allowing direct access to the biceps
tendon sheath within the bicipital groove. A

Fig. 4.13 Ultrasound images (a and b) demonstrate nee-

dle placement, for SASD bursal injection, with the tip of
the needle (block arrow) within the echogenic peribursal
fat (thin arrows). Postinjection, there is smooth distention
of the SASD bursal with injectate (*, b). Note that the
bursa extends lateral to the rotator cuff insertion. Ssp
supraspinatus, GT greater tuberosity Fig. 4.14 Patient positioning and needle placement for
LHBT US-guided injection
25-gauge 1.5 in.needle or a 22-gauge 3.5 in. nee- can also be confirmed by scanning the LHBT
dle may be used for injection, depending on the in long axis, which should demonstrate distal
patient’s body habitus. 3–4 mL of an anesthetic spread of injectate. Ultrasound-guided injec-
and cortisone mixture is typically injected for tion of the LHBT has shown to significantly
therapeutic purposes. The transducer is placed reduce needle misplacement as compared with
transversely over the bicipital groove, providing the blinded method (86% vs. 26%, respec-
a short-axis view of the LHBT. The needle should tively) [17].
be inserted into the tendon sheath at the level of
the bicipital groove in plane to the transducer via
a lateral-to-medial approach (Fig. 4.14). Fluid 4.7 Acromioclavicular Joint
within the tendon sheath is an excellent target, if
present. Rocking the transducer will help to dis- The acromioclavicular (AC) joint is well seen
tinguish anisotropy of the LHBT, which is nor- under US and can be found by scanning laterally
mally echogenic, from fluid within the tendon along the superior aspect of the clavicle. For
sheath. Doppler imaging should also be used to US-guided injection, the patient is positioned
identify and avoid the anterior humeral circum- supine, with the arm by the side in a neutral posi-
flex artery, which is often seen just lateral to the tion. The injection can be easily performed with a
LHBT. 25-gauge 1.5 in. needle. With an intact joint cap-
The needle should be advanced into the ten- sule, usually not more than 1 mL can be injected
don sheath so that the tip sits adjacent to the into the AC joint. With advanced AC joint arthro-
superficial or deep aspect of the LHBT sis, injectate may decompress into the SASD
(Fig. 4.15a). Once the needle appears to be in a bursa.
satisfactory position, a test injection with anes- The AC joint can be injected via an in-plane
thetic should be performed to confirm appro- or out-of-plane approach. With an out-of-
priate needle positioning. The lidocaine should plane approach, the AC joint should be scanned
smoothly distend the biceps tendon sheath in long axis with the transducer placed longi-
(Fig. 4.15b). Subsequently, the therapeutic tudinally over the AC joint and the needle
mixture can be injected, and the injectate advanced out of plane (i.e., short axis) to the
should circumferentially coat the transducer (Fig. 4.16a). Using this approach,
LHBT. Distention of the biceps tendon sheath both the acromion and clavicle are visualized
a b
Fig. 4.15 Ultrasound images (a, b) demonstrate needle LHBT sheath with the injectate (b,*). H humeral head, b
placement (arrow) within the LHBT sheath (circle). biceps tendon
During injection, there is circumferential distention of the
on the same image, and the tip of the needle

a
will be seen en face as an echogenic dot
(Fig. 4.16b).
For an in-plane approach, the transducer is
placed transversely over the AC joint and the
needle is advanced in plane to the transducer.
The joint space can be found by scanning later-
ally from the clavicle or medially from the acro-
mion. The hypoechoic space between the
clavicle and acromion is the joint space
(Fig. 4.17). Neither the clavicle nor the acro-
mion will be seen on the sonographic image
during this in-plane injection; only the joint
space will be visualized. The needle shaft and
tip should be visualized as the tip is inserted into
b the joint space (Fig. 4.18).
Once the needle appears to be within the
joint space, a test injection should be per-
formed to confirm intra-articular needle posi-
tioning with smooth distention of the joint
space. Subsequently, the therapeutic mixture
can be injected. A recent report has shown
that ultrasound-guided AC joint injections
have better outcome as compared with
Fig. 4.16 (a) Patient positioning and needle placement blinded injections due to the improved accu-
for out-of-plane AC joint injection. (b) The echogenic tip racy [18].
of the needle (arrow) is seen within the acromioclavicular
joint. Ac acromion, Cl clavicle
Fig. 4.17 Ultrasound images demonstrate the appearance of the acromioclavicular joint via an in-plane approach. The
joint space (asterisk) is located between the clavicle (Cl), which is lateral, and the acromion (Ac), which is medial
a a
b
b
Fig. 4.19 (a) Patient positioning and needle placement

for out-of-plane SC joint injection. (b) Simulated echo-
genic needle tip (round dot) within the SC joint (circle)
joint and the needle advanced straight down, out

of plane to the transducer (Fig. 4.19a). Using this
Fig. 4.18 (a) Patient positioning and needle placement approach, both the sternum and clavicle are visu-
for in-plane AC joint injection. (b) The entire length of the
needle (arrows) is seen as it is advanced into the joint alized on the same image, and the tip of the nee-
space (circle) dle will be seen as an echogenic dot (Fig. 4.19b).
With this technique, the operator must be aware
of the depth of the needle tip at all times to avoid
4.8 Sternoclavicular Joint inadvertent injury to critical structures deep to
the SC joint.
Similar to the AC joint, the sternoclavicular (SC) For an in-plane approach, the transducer is
joint is superficial and well seen on US. The placed transversely over the SC joint and the nee-
patient should be supine, with the arm by the side dle is advanced in an oblique cranial direction, in
in a neutral position. The injection is easily per- plane to the transducer (Fig. 4.20a). The joint
formed with a 25-gauge 1.5 in. needle. A thera- space can be found by scanning laterally from the
peutic volume of 1–2 mL of an anesthetic and clavicle or medially from the sternum. The
cortisone mixture is recommended. The SC joint hypoechoic space between the clavicle and acro-
can be found by scanning longitudinally along mion is the joint space. As with the AC joint, the
the anterior aspect of the clavicle and moving needle shaft and tip should be seen as the tip is
medially over the clavicular head until the lateral inserted into the SC joint space (Fig. 4.20b).
border of the manubrium is visualized. An alternative SC joint in-plane injection is
The injection technique is similar to that of the performed with the transducer placed over the
AC joint. With an out-of-plane approach, the SC sternoclavicular joint in long axis, with the nee-
joint should be scanned in long axis with the dle inserted in either a medial-to-lateral or a
transducer placed longitudinally over the SC lateral-
to-medial direction, using the
a a
b
b
Fig. 4.20 (a) Patient positioning and needle placement

for in-plane SC joint injection. (b) Simulated needle tra- Fig. 4.21 (a) Patient positioning and needle placement
jectory (dotted line) to target the SC joint for alternate in-plane SC joint injection. (b) The entire
length of the needle is seen (arrow), with the needle tip
within the SC joint (circle) and the clavicular head acting
as a backstop. Cl clavicular head, St sternum
anubrium or clavicular head as a backstop for

m so the injection should be performed at the site of
the needle tip, respectively (Fig. 4.21). This in- the patient’s maximum discomfort. The patient
plane approach also allows for constant visual- should be placed in a prone or prone oblique
ization of the needle tip and prevents inadvertent position, with the arm by the side (Fig. 4.23a). A
injury to critical structures deep to the SC joint. 25-gauge 1.5 in. needle is typically used for this
Once the needle appears to be within the joint injection, although a 22-gauge 3.5 in. needle can
space, a test injection with anesthetic can be also be used if required, depending on the
performed to confirm intra-articular needle patient’s body habitus. The dose should consist
positioning and should result in capsular dis- of 2–3 mL of an anesthetic and cortisone
tention. Once confirmed, the therapeutic mix- mixture.
ture may be injected. The space between the medial border of the
scapula and rib should be targeted using a hori-
zontal, medial-to-lateral needle approach
4.9 Scapulothoracic Bursa (Fig. 4.23a). An in-plane approach is used for
injection, with the transducer placed trans-
The scapulothoracic bursa is located deep to the versely over the scapulothoracic bursa medial
scapula and superficial to the ribs (Fig. 4.22). border of the scapula. The injection should be
Scapulothoracic bursal injection can easily and performed at the level of a rib in order to pro-
safely be performed under US guidance. A dis- vide a backstop, and the needle shaft should
tended bursa is almost never visible on US, and always be visualized as it is advanced deep to
a a
Scapula Posterior
Bursa
Rib
Humerus
Anterior b
Fig. 4.23 (a) Patient positioning and needle placement.

(b) Ultrasound image demonstrates needle placement
(arrow) targeting the scapulothoracic bursa. Sc scapula
Fig. 4.22 Illustration (a) and ultrasound image (b) of the A diagnostic US should first be performed to
region of the scapulothoracic bursa. The bursa is not seen
on US but is located between the scapular blade (Sc) and
identify the location and size of the calcific
the rib deposits (Fig. 4.24). If multiple calcific deposits
are present, the largest deposits should be tar-
the scapula (Fig. 4.23b). It is imperative to stay geted. Echogenic calcific deposits may or may
superficial to the ribs in order to prevent a not demonstrate associated shadowing, and some
pneumothorax. will reveal associated hyperemia with Doppler
evaluation [12, 22, 23].
Patient positioning will depend on the loca-
4.10 Calcific Tendinosis Lavage tion of the calcific deposits to be targeted.
and Aspiration However, the procedure will typically be per-
formed with the patient in a supine or lateral
Hydroxyapatite crystal deposition in the shoulder decubitus position. An 18-gauge needle should
most commonly involves the rotator cuff tendons be used, and the needle length can be 1.5 or
(calcific tendinosis) and/or the SASD bursa (cal- 3.5 in., depending on the patient’s body habitus.
cific bursitis). Lavage and aspiration of the cal- One- and two-needle aspiration techniques have
cific deposits under US guidance is an effective been reported [20, 23, 24]. The lavage medium
method for treatment of calcific tendinosis, and it may consist of sterile saline alone, lidocaine
has been shown to give longer lasting relief than alone, or saline with lidocaine in a 50–50 admix-
corticosteroid injection into the SASD bursa ture. Some advocate the use of warmed saline in
alone [19–21]. calcific tendinosis lavage, reporting improved
Fig. 4.24 Ultrasound image demonstrates an echogenic,

shadowing focus of calcification (arrow) within the supra-
spinatus tendon, reflecting calcific tendinosis. Ssp supra-
spinatus tendon, GT greater tuberosity
calcium dissolution and lower incidence of post-

procedural bursitis [25]. Our technique is to use b
multiple aliquots of the lavage mixture, prefera-
bly in 5 or 10 mL syringes, and a one-needle
aspiration technique. The needle should be
directed into the center of the calcific deposit via
an in-plane approach and the tip should be posi-
tioned in the center of the calcific deposit
(Fig. 4.25). It is important to accurately puncture
the calcific deposit in one pass, as this will help
maintain pressure within the deposit during
lavage. The saline syringe should be attached to
the needle once it is in proper position and pulsed Fig. 4.25 (a) Patient positioning and needle placement.
lavage should begin by applying repeated com- (b) Ultrasound image demonstrates optimal needle place-
pression on the plunger of the syringe. Initial ment (arrow) with the needle tip at the center of the cal-
breakdown of the calcific deposit may occur cific deposit (circle). Ssp supraspinatus tendon, GT greater
tuberosity
with a palpable pop. Repeated plunger compres-
sion will cause further breakdown of the calcific
deposit and calcific particles will be seen to waft
back into the syringe each time the plunger is
released (Fig. 4.26).
As lavage is performed, a hypoechoic, fluid-
filled cavity will be created within the center of
the calcific deposit. As fluid is pushed into the
calcific deposit, the cavity will expand, and as it
is withdrawn the cavity will collapse (Fig. 4.27).
This is indicative of an effective lavage, and has
been likened to a “fishmouth” appearance. Once
the fluid in the syringe is cloudy and filled with
calcium, the syringe should be replaced with a Fig. 4.26 Photograph depicts calcium (arrows) wafting
fresh saline syringe. Lavage should be performed into a syringe of saline during calcific tendinosis lavage
a b
Fig. 4.27 (a and b) Ultrasound images demonstrate distention (a) and decompression (b) of the cavity (circle) within
the calcific deposit during lavage and aspiration, producing a “fishmouth” appearance in real time. Arrow—needle
4.11 Ganglion/Paralabral Cyst

Aspiration
Paralabral cysts are thought to occur due to

injury of the capsulolabral complex, and indicate
the presence of a labral tear. Synovial fluid can
leak from the joint, through the tear, and into the
para-articular soft tissues, resulting in the devel-
opment of a paralabral cyst. In the shoulder,
these cysts are most commonly seen in the
spinoglenoid notch and may extend into the
suprascapular notch. US can detect paralabral
cysts about the shoulder, particularly within the
spinoglenoid notch [26] (Fig. 4.29), and can be
used for guidance of aspiration and fenestration
Fig. 4.28 Following lavage and aspiration of calcium, of these cysts.
the needle (arrow) can be redirected into the overlying Spinoglenoid or suprascapular notch paral-
SASD bursa (asterisk) for cortisone injection. Ssp supra-
spinatus tendon, GT greater tuberosity abral cyst aspiration can be performed in a prone,
prone oblique, or lateral decubitus position,
until calcium is no longer visualized entering depending on the cyst location. An 18-gauge nee-
the syringe. As the lavage of the calcium pro- dle is recommended, as the contents are usually
gresses, fluid injected into the calcific nidus viscous, and the length of the needle will vary
may be seen to decompress into the overlying depending on the depth of the cyst. The cyst may
SASD. be targeted with the needle in plane to the trans-
Following calcium lavage and aspiration, the ducer via a medial-to-lateral or lateral-to medial
needle can be redirected into the overlying SASD approach (Fig. 4.30). Before and while advanc-
bursa, and bursal injection with anesthetic and ing the needle, it is important to look for the
cortisone mixture should be performed using the suprascapular neurovascular bundle which is
same technique as described above in the SASD located in the region of the spinoglenoid notch.
bursa section (Fig. 4.28). Performing this Color or power Doppler imaging can be useful
injection will help to prevent or minimize symp- for identification. Once the needle tip is inserted
toms associated with painful calcific bursitis after into the center of the paralabral cyst, the fluid
the procedure is completed. within the cyst should be aspirated, with the aim
a b
Fig. 4.29 Axial T1-weighted MR image (a) and corre- The spinoglenoid notch is located deep to the infraspina-
sponding ultrasound image (b) demonstrate a paralabral tus. In infraspinatus muscle, G glenoid
cyst (asterisk) within the spinoglenoid notch (arrows).
Fig. 4.30 Patient positioning and needle placement for

aspiration of a spinoglenoid cyst
of complete decompression of the cyst (Fig. 4.31).

Lavage by injection of anesthetic and re-
aspiration may aid in complete decompression.
Subsequently, the cyst wall should be fenestrated
with multiple needle passes. Following paral-
abral cyst aspiration and fenestration, a mixture
of 1–2 mL of anesthetic and cortisone can be
Fig. 4.31 Ultrasound images (a, b) demonstrating a nee-
injected into the region of the decompressed cyst, dle (arrows) within the spinoglenoid notch cyst (circles).
with care taken not to re-distend the cyst. Post-aspiration (b), there is decompression of the spino-
Alternatively, the anesthetic-cortisone mixture glenoid notch cyst
may be used to lavage the cyst cavity during fen- 11. Jacobson JA. Fundamentals of musculoskeletal ultra-
estration, and any excess of the mixture is re- sound. Philadelphia, PA: Saunders/Elsevier; 2007.
p. 345.
aspirated to avoid leaving the cyst distended. 12. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids
Although evidence is sparse, cortisone injection to successful shoulder arthrography performed
is thought to diminish inflammation which is pro- with a fluoroscopically guided anterior approach.
posed as a pain generator and a causative factor Radiographics. 2003;23:373–8.. discussion 379
13. Miller TT. MR arthrography of the shoulder and
in cyst formation [26, 27]. Corticosteroid injec- hip after fluoroscopic landmarking. Skelet Radiol.
tion in the region of the cyst may also help 2000;29:81–4.
decrease inflammation of the suprascapular 14. Chung CB, Dwek JR, Feng S, Resnick D. MR arthrog-
nerve, which is commonly entrapped in patients raphy of the glenohumeral joint: a tailored approach.
AJR Am J Roentgenol. 2001;177:217–9.
with symptomatic paralabral cysts in the shoul- 15. Farmer KD, Hughes PM. MR arthrography of
der [26, 28, 29]. the shoulder: fluoroscopically guided technique
using a posterior approach. AJR Am J Roentgenol.
2002;178:433–4.
16. Molini L, Mariacher S, Bianchi S. US guided corti-
References costeroid injection into the subacromial- subdeltoid
bursa: technique and approach. J Ultrasound.
1. Otjen J, Parnell SE, Menashe S, Thapa 2012;15:61–8.
MM. Ultrasound-guided joint injections for MR 17. T H, Sakurai G, Morimoto M, Komei T, Takakura Y,
arthrography in pediatric patients: how we do it. Tanaka Y. Accuracy of the biceps tendon sheath injec-
Pediatr Radiol. 2015;45:308–16.. quiz 305-7 tion: ultrasound-guided or unguided injection? A ran-
2. Valls R, Melloni P. Sonographic guidance of needle domized controlled trial. J Shoulder Elb Surg. 2011
position for MR arthrography of the shoulder. AJR Oct;20(7):1069–73.
Am J Roentgenol. 1997;169:845–7. 18. Park KD, Kim TK, Lee J, Lee WY, Ahn JK, Park
3. Gokalp G, Dusak A, Yazici Z. Efficacy of Y. Palpation versus ultrasound-guided acromiocla-
ultrasonography- guided shoulder MR arthrography vicular joint intra-articular corticosteroid injections:
using a posterior approach. Skelet Radiol. a retrospective comparative clinical study. Pain
2010;39:575–9. Physician. 2015;18(4):333–41.
4. Ogul H, Bayraktutan U, Ozgokce M, et al. Ultrasound- 19. de Witte PB, Selten JW, Navas A, et al. Calcific ten-
guided shoulder MR arthrography: comparison of dinitis of the rotator cuff: a randomized controlled
rotator interval and posterior approach. Clin Imaging. trial of ultrasound-guided needling and lavage ver-
2014;38:11–7. sus subacromial corticosteroids. Am J Sports Med.
5. Ng AW, Hung EH, Griffith JF, Tong CS, Cho 2013;41:1665–73.
CC. Comparison of ultrasound versus fluoroscopic 20. del Cura JL, Torre I, Zabala R, Legorburu
guided rotator cuff interval approach for MR arthrog- A. Sonographically guided percutaneous needle
raphy. Clin Imaging. 2013;37:548–53. lavage in calcific tendinitis of the shoulder: short-
6. Rutten MJ, Collins JM, Maresch BJ, et al. and long-term results. AJR Am J Roentgenol.
Glenohumeral joint injection: a comparative study 2007;189:W128–34.
of ultrasound and fluoroscopically guided techniques 21. Levy O. Ultrasound-guided barbotage in addition to
before MR arthrography. Eur Radiol. 2009;19:722–30. ultrasound-guided corticosteroid injection improved
7. Schneider R, Ghelman B, Kaye JJ. A simplified injec- outcomes in calcific tendinitis of the rotator cuff. J
tion technique for shoulder arthrography. Radiology. Bone Joint Surg Am. 2014;96:335.
1975;114:738–9. 22. Le Goff B, Berthelot JM, Guillot P, Glemarec J,
8. Mulligan ME. CT-guided shoulder arthrography Maugars Y. Assessment of calcific tendonitis of rota-
at the rotator cuff interval. AJR Am J Roentgenol. tor cuff by ultrasonography: comparison between
2008;191:W58–61. symptomatic and asymptomatic shoulders. Joint Bone
9. Soh E, Bearcroft PW, Graves MJ, Black R, Lomas Spine. 2010;77:258–63.
DJ. MR-guided direct arthrography of the glenohu- 23. Saboeiro GR. Sonography in the treatment of cal-
meral joint. Clin Radiol. 2008;63:1336–41.. discus- cific tendinitis of the rotator cuff. J Ultrasound Med.
sion 1342-3 2012;31:1513–8.
10. Hilfiker PR, Weishaupt D, Schmid M, Dubno B, 24. Sconfienza LM, Vigano S, Martini C, et al. Double-
Hodler J, Debatin JF. Real-time MR-guided joint needle ultrasound-guided percutaneous treatment of
puncture and arthrography: preliminary results. Eur rotator cuff calcific tendinitis: tips & tricks. Skelet
Radiol. 1999;9:201–4. Radiol. 2013;42:19–24.
25. Sconfienza LM, Bandirali M, Serafini G, et al. 27. Breidahl WH, Adler RS. Ultrasound-guided injec-
Rotator cuff calcific tendinitis: does warm saline tion of ganglia with corticosteroids. Skelet Radiol.
solution improve the short-term outcome of 1996;25:635–8.
double-needle US-guided treatment? Radiology. 28. Biedert RM. Atrophy of the infraspinatus muscle
2012;262:560–6. caused by a suprascapular ganglion. Clin J Sport Med.
26. Hashimoto BE, Hayes AS, Ager JD. Sonographic 1996;6:262–3.. discussion 264
diagnosis and treatment of ganglion cysts causing 29. Neviaser TJ, Ain BR, Neviaser RJ. Suprascapular
suprascapular nerve entrapment. J Ultrasound Med. nerve denervation secondary to attenuation by a gan-
1994;13:671–4. glionic cyst. J Bone Joint Surg Am. 1986;68:627–8.
Part II
Rotator Cuff, Biceps and Rotator Interval
Imaging Diagnosis of Rotator Cuff
Pathology and Impingement 5
Syndromes
Eric Y. Chang and Christine B. Chung
5.1 Introduction anatomic variables external to the tendon, such as

the various impingement syndromes.
Rotator cuff disease, which includes tendinopa- In most patients, it is generally favored that
thy and tearing, is incredibly common. A system- intrinsic mechanisms play a greater role in cuff
atic review in 2014 has shown that the prevalence disease compared with extrinsic factors [14–18].
of rotator cuff disease increases with age, from This is referred to as the intrinsic theory of cuff
approximately 10% in patients under 20 years of disease, which states that cuff dysfunction is the
age to approximately 60% in patients greater causal abnormality, leading to decentering of the
than 80 years of age [1]. There are a number of humeral lead and resultant formation of entheso-
controversies that exist when discussing the rota- phytes and tuberosity lesions [19]. Although bio-
tor cuff, including symptomatology and pathoeti- logically engineered scaffolds [20], exogenous
ology. Although it is clear that cuff disease can be growth factors [21], and cellular therapies [22]
symptomatic and necessitate treatment, the deter- targeting intrinsic mechanisms are increasing,
mination of which abnormalities are symptom- surgical therapy of cuff disease and treatment of
atic or which are best treated with surgical associated extrinsic lesions remain the most
intervention remains a challenge [2–6]. widely available nonconservative treatment
The etiology of rotator cuff disease is multi- options. Therefore, it is critical for the radiologist
factorial with intrinsic and extrinsic contributions and surgeon to identify the lesions that can be
[7, 8]. Intrinsic mechanisms are associated with associated with shoulder pain and cases which
the tendon itself and the degenerative- may be amenable to available treatment.
microtrauma model is likely to be critical to the The diagnosis of impingement syndromes
development of cuff disease in many patients [9]. requires all available information, including his-
This model supposes that age-related tendon tory, physical examination, and imaging. A prac-
damage [10, 11] compounded by chronic, repeti- tical and commonly used classification scheme of
tive microtrauma results in adverse cellular the various shoulder impingement syndromes is
changes, release of inflammatory mediators, and to divide based on those where the pathogenesis
apoptosis [12, 13]. Extrinsic mechanisms include resides outside the glenohumeral joint capsule
(termed external impingement) and those resid-
ing inside the glenohumeral joint capsule (termed
E. Y. Chang (*) · C. B. Chung
Department of Radiology, VA San Diego Healthcare internal impingement). External impingement
System, San Diego, CA, USA syndromes include subacromial impingement
Department of Radiology, University of California, and subcoracoid impingement. Internal impinge-
San Diego Medical Center, San Diego, CA, USA ment syndromes include posterosuperior

88 E. Y. Chang and C. B. Chung
impingement, which belongs in the spectrum of Burkhart et al. outlined the function of the
abnormalities leading to the disabled throwing rotator cable-crescent complex in 1993 [28].
shoulder, and anterosuperior impingement. Each Much like a suspension bridge, the rotator cuff
impingement syndrome is a distinct entity, pre- and cable have anterior and posterior supporting
dominantly affecting different demographics of limbs, represented by the anterior attachment of
patients, but more than one type of impingement the supraspinatus tendon and the posterior attach-
syndrome may be seen in an individual. ment of the infraspinatus tendon, respectively.
This chapter reviews (1) the imaging anatomy Tears that occur in the thinner, crescentic portion
of the structures related to impingement, includ- of the cuff between the two intact limbs are felt to
ing the rotator cuff and biceps pulley; (2) the be stress-shielded by the cable, explaining why
multi-modality imaging manifestations of rotator some cuff tears may be less biomechanically sig-
cuff disease and the various shoulder impinge- nificant [28]. In contrast, tears of the rotator cable
ment syndromes; and (3) the expected and abnor- itself or of the supporting limbs can have dire
mal appearances after surgical therapy. biomechanical consequences and should be con-
sidered for early repair [33–36]. While the rotator
cable is consistently identified on anatomic dis-
5.2 Imaging Anatomy sections and at surgery [28, 37, 38], it can be seen
frequently but not invariably on imaging [37–40].
The supraspinatus, infraspinatus, teres minor, This may be due to the less conspicuous appear-
and subscapularis contribute to the rotator cuff. ance on imaging (Fig. 5.1b).
The rotator cuff is composed of approximately The deepest layer of the rotator cuff is the gle-
75% water and the dry weight composition is nohumeral joint capsule [25]. Although previ-
approximately 67% type I collagen [23] and ously thought to be only 1–2 mm thick [25],
1–5% proteoglycan/glycosaminoglycan [24]. Nimura et al. found a much more substantial con-
The rotator cuff ultrastructure is complex, with tribution of the capsule to the rotator cuff, repre-
up to five distinct layers that are visible with his- senting more than half the total tendon width at
tological evaluation [25] or MR imaging [26, 27]. some locations. According to Nimura et al., the
An important component of the rotator cuff is minimum capsular width was 3.5 mm, located
the rotator cable [28]. Of note, the term rotator near the posterior portion of the supraspinatus
cable is most commonly utilized in the radiologi- footprint, and this was suspected to represent the
cal literature; however the same structure has crescent [41]. The joint capsule was found to be
been described under different names, including thickest at the anterior margin of the greater
the ligamentum semicirculare humeri [29, 30], tuberosity and posterior margin of the infraspina-
the transverse band [25], and the circular fiber tus tendon, measuring 5.6 and 9.1 mm on aver-
system [31]. The rotator cable has been described age, respectively [42]. These are believed to
to be an extension of fibrous tissue extending represent the greater tuberosity attachment sites
through the rotator interval, which has been of the rotator cable [41].
termed the coracohumeral ligament (CHL) [25, Our understanding of anatomy pertinent to
32] or the coracoglenohumeral ligament (CGHL) each rotator cuff muscle and tendon continues to
[30] (Fig. 5.1a). The differences in terminology evolve. Classic descriptions in standard anatomi-
reflect the different perspectives of the dense con- cal textbooks [43, 44] are now known to be inac-
nective tissue in the rotator interval. While some curate or incomplete since significant
consider the CHL and superior glenohumeral contributions to the literature have occurred
ligament (SGHL) as separate structures, others within the last decade. Each cuff component has
have suggested that these structures be consid- unique anatomical considerations that are impor-
ered a single functional unit, called either the tant to biomechanical function. This is particu-
CHL (with the SGHL representing a limited por- larly relevant to the radiologist for diagnosis and
tion of this structure) [32] or the CGHL [30]. to the orthopedic surgeon for anatomic
5 Imaging Diagnosis of Rotator Cuff Pathology and Impingement Syndromes 89
a b
Humeral Humeral
Head Head
Fig. 5.1 Left shoulder of a cadaveric specimen (94-year- Diffuse chondrosis is present over the humeral head. (b)
old man). (a) Photograph of dissection, viewed from Coronal oblique intermediate-weighted MR image of the
anterosuperior, after reflection of the rotator cuff and cap- same specimen shows the rotator cable as a thickening of
sule shows a distinct rotator cable (thick arrows), which is the deep surface of the supraspinatus tendon (thick white
a continuation of the coracohumeral ligament (black arrow), which is less apparent compared with the gross
dashed arrow). The superior glenohumeral ligament image. Dissected specimen is imaged in air, which
(black arrow) inserts onto the fovea capitis of the humerus. appears black in the image
restoration. Pertinent soft tissue and osseous times. Our current knowledge of the supraspina-
anatomy for each component is further described tus footprint is that it predominantly occupies the
below. anteromedial portion of the superior facet (or
highest impression) of the greater tuberosity and
is triangular or trapezoidal in shape [50, 51]. The
5.2.1 Supraspinatus lateral-most attachment extends over the lip of
the greater tuberosity [48]. Anatomic studies
The supraspinatus muscle originates from supra- have shown that in approximately a quarter of
spinous fossa as well as the superior surface of specimens, fibers from the anterior tendon of the
the scapular spine and is composed of distinct supraspinatus cover the bicipital groove and
anterior and posterior muscle bellies. The ante- attach to the lesser tuberosity [50, 51]. Moser
rior muscle belly is approximately 3–6 times et al. described an “aponeurotic expansion” of
larger and also demonstrates a larger variation of the anterior supraspinatus tendon, coursing ante-
pennation angles compared with the posterior rior and lateral to the long head of the biceps ten-
belly [45, 46]. The greater force generation and don, inserting distally onto the pectoralis major
different contraction forces present within the tendon and evident in approximately half of their
anterior belly may explain the higher incidence cadaveric shoulders and clinical cases [52, 53].
of anterior tendon tears [45, 47]. According to Moser et al., this same structure has
The anterior belly gives rise to a longer, cord- been previously mistermed a fourth head of the
like tendon whereas the posterior belly gives rise pectoralis major [54] and an accessory biceps
to a shorter, quadrangular shaped tendon [45] tendon [55–57]. Precise delineation of the anat-
(Fig. 5.2). The humeral attachment of the rotator omy in the anterosuperior aspect of the shoulder
cuff tendon is frequently referred to as the foot- requires reconciliation of the rapidly evolving
print, a term coined by Tierney et al. in 1999 anatomical, surgical, and imaging literature.
[48]. The footprint of the supraspinatus was first The dimensions of the cuff footprint are clini-
delineated by Minagawa et al. [49], but has sub- cally relevant since partial-thickness tears should
sequently been redefined and refined several be graded as low, moderate, or high grade based
a b e
c d
Fig. 5.2 Anatomy and pathology of the anterior muscle mial-subdeltoid bursitis was present (not shown). (c and d)
belly of the supraspinatus in a 50-year-old man. (a and b) 4 years later, calcium hydroxyapatite had migrated towards
Sagittal oblique T1-weighted and T2-weighted fat- the myotendinous junction of the anterior belly with sur-
suppressed MR images, respectively, show calcium rounding edema (thin arrow) which separates the tendons
hydroxyapatite deposition in the supraspinatus tendon near of the anterior and posterior muscle bellies of the supraspi-
the footprint (thick arrow). More medially, cordlike tendon natus. (e) Concurrent radiograph confirms intra-tendinous
of anterior belly is evident (open arrow). Mild subacro- migration of crystals (thin arrows)
on depth [58] and anatomic restoration in the supraspinatus footprint is not as large as previ-
setting of repair requires knowledge of the foot- ously described, mean length (anterior-posterior
print. Unfortunately, reported cuff footprint dimension) measures approximately 20.9–32 mm
dimensions have varied widely in the literature, medially and 1.3–6.4 mm laterally [50, 51]. In
likely due to a combination of variables, includ- contrast to gross measurements, there is a paucity
ing the precise delineation of the boundaries of of imaging-based tendon measurements, which
the footprint, differences in degrees of capsular some may argue would be the most useful for
dissection from the tendon [42], as well as indi- clinical practice. Karthiekeyan et al. [62] per-
vidual variation such as age, gender, patient size, formed ultrasound-based measurements in 120
and race. For instance, Curtis et al. described that young healthy shoulders and found mean supra-
the supraspinatus tendon extends over the lateral spinatus footprint widths of 14.9 mm in men and
lip of the greater tuberosity [48]; however it is 13.5 mm in women. In the same study, mean
likely that the authors were measuring a portion supraspinatus tendon thickness was 5.6 mm in
of the infraspinatus footprint onto what is now men and 4.9 mm in women.
called the lateral facet [59] (discussed in further
detail below). On cadaveric studies, mean supra-
spinatus footprint width (medial-lateral dimen- 5.2.2 Infraspinatus
sion) has been reported to vary considerably,
ranging from 6.7 to 16 mm [42, 46, 48, 50, 51, The infraspinatus muscle originates from the
60, 61]. Based on the current concept that the infraspinous fossa as well as the inferior surface
of the scapular spine and is composed of two range from 6.9 to 15.1 mm [42, 48, 50, 51, 60].
distinct portions. The oblique (or inferior) por- Based on the current concept that the footprint
tion is approximately four to five times larger of the infraspinatus occupies the entire middle
than the transverse (or superior) portion [63, facet and approximately half of the superior
64]. The infraspinatus tendon attaches to the facet (or lateral facet), the mean length (ante-
greater tuberosity and, similar to the supraspina- rior-posterior dimension) measures 22.9 mm
tus, the footprint has also been redefined and medially and 25.6–32.7 mm laterally [50, 51].
refined several times in recent years. Kato et al. Of note, Mochizuki et al. found a far anterolat-
demonstrated that the footprint is entirely com- eral extent of the infraspinatus footprint, with
posed of the tendon arising from the oblique mean distance between the most anterior edge
portion and that the tendon of the transverse of the footprint and the bicipital groove measur-
portion is membrane-like and attaches to the ing 1.3 mm [51]. Lumsdaine et al. found a
posterior surface of the tendinous portion of the greater mean distance between the most anterior
oblique part [63, 64]. edge of the infraspinatus footprint and the bicip-
The greater tuberosity footprint of the ital groove, measuring 6.4 mm [50]. The differ-
oblique portion is larger than what has been ences may be due to ethnic variation since
historically described. Standard anatomical Mochizuki et al. used 128 shoulders from
textbooks recognize three facets (or impres- Japanese donors whereas Lumsdaine et al. used
sions) of the greater tuberosity: superior (or 54 shoulders from Australian Caucasoid donors.
horizontal), middle (or oblique), and inferior Using ultrasound on young healthy shoulders,
(or vertical) [43, 44]. More recent studies have Karthiekeyan et al. [62] found that the mean
suggested that the infraspinatus footprint occu- thickness of the infraspinatus tendon measures
pies the entire middle facet and approximately 4.9 mm in men and 4.4 mm in women. Michelin
half of the superior facet [50, 51]. However, in et al. measured a mean infraspinatus tendon
2015, Nozaki et al. proposed a fourth facet (or thickness of 2.2 mm on MRI [67] and 2.4 mm
impression) of the greater tuberosity, which on ultrasound [68].
they termed the lateral facet (Fig. 5.3) [59].
The lateral facet is triangular in shape, variable
in size, located posterolateral to the superior 5.2.3 Teres Minor
facet, and was recognized in all 87 specimens
of their study. The authors demonstrated that The teres minor muscle originates from the mid-
the anterior extent of the infraspinatus foot- dle portion of the lateral edge of the scapula and
print is onto the lateral facet. The orientation of a variable dense fascia of the infraspinatus mus-
the facets of the humeral tuberosities is related cle [69]. At the myotendinous junction, the teres
to rotator cuff muscle function and may repre- minor appears as superior and inferior bundles
sent an anatomical factor involved in patho- [70]. The superior bundle originates from the lat-
genesis of rotator cuff tears [65, 66]. Le eral edge of the scapula and inserts onto the infe-
Corroller et al. demonstrated that a decrease in rior facet as an oval footprint. The inferior bundle
dorsal orientation of the middle facet in the originates from both the lateral edge of the scap-
sagittal plane was associated with higher like- ula and a dense fascial septum between the infra-
lihood of cuff tearing [65]. spinatus and teres minor muscles, and attaches as
Similar to the supraspinatus tendon, the a band to the surgical neck of the humerus. Saji
reported infraspinatus footprint dimensions et al. dissected seven shoulders and found that the
have varied widely in the literature. On cadav- dense fascia was aplastic in one case. In the set-
eric studies, mean infraspinatus footprint width ting of an absent fascia, the teres muscle extends
(medial-lateral dimension) has been reported to to cover the infraspinatus and the borders between
a b
c d
Fig. 5.3 30-Year-old man with a large lateral facet of the eral facet (thick arrows), which is located posterolateral to
greater tuberosity as described by Nozaki et al. (a and b) the superior facet and represents the anterior infraspinatus
Volume-rendered CT images shows the lateral facet in footprint and the bursal side of the cuff at this location.
profile (a, thick arrow) and en face (b, dashed outline). Also evident is moderate-grade partial-thickness articular
Superior (arrowhead) and middle (open arrow) facets are sided tearing of the supraspinatus tendon (dashed arrow)
marked. (c and d) Coronal oblique CT and T1-weighted and posterosuperior labral tearing with adjacent chondral
fat-suppressed MR arthrogram images show the large lat- damage (thin arrow)
the infraspinatus and teres minor muscles can be 5.2.4 Subscapularis

difficult to identify on MR imaging [71]
(Fig. 5.4). The subscapularis muscle originates from the
Similar to the rest of the cuff, reported mean medial two-thirds of the anterior surface of the
dimensions of the footprint vary widely in the lit- scapula [72]. The superior two-thirds of the sub-
erature. On cadaveric studies, mean width scapularis muscle transitions to tendon at the
(medial-lateral dimension) ranges from 11.4 to level of the glenoid and blends with joint capsule
21 mm and mean length (superior-inferior dimen- fibers before inserting onto the lesser tuberosity
sion) ranges from 20.7 to 29 mm [48, 60]. [73, 74]. The inferior one-third is the so-called
a b
c d
Fig. 5.4 Anatomic variations and pathology of the teres and coronal oblique T1-weighted images in a 53-year-old
minor muscle. (a) Sagittal oblique T1-weighted image of man with selective atrophy of the superior bundle of the
a 21-year-old woman with well-delineated infraspinatus teres minor muscle. An oval-shaped tendon arises from
(thick arrow) and teres minor (thin arrow) muscles. (b) the atrophic superior muscle bundle (open arrow) and
Sagittal oblique T1-weighted image of a 23-year-old attaches onto the inferior facet of the greater tuberosity.
woman with an indistinct boundary between the infraspi- The normal inferior bundle attaches onto the posterior
natus (thick arrow) and teres minor (thin arrow) muscles, aspect of the surgical neck of the humerus (arrowhead)
indicating a hypoplastic fascial septum. (c and d) Sagittal
muscular insertion, attaching onto the surgical posed of several smaller intramuscular tendons
neck of the humerus via a thin, membranous and the superior-most insertion is a thin slip,
structure [66, 73, 74]. which attaches to the fovea capitis of the humerus
Similar to the rest of the cuff, our knowledge [70, 73] (Fig. 5.5). Many authors have found that
of the subscapularis tendon and footprint contin- the superior glenohumeral ligament also attaches
ues to evolve. The subscapularis tendon is com- to the fovea capitis [75–77], although some have
a b
F1
F2
F3
F4
c d
GT
LT
Fig. 5.5 Subscapularis anatomy and pathology. (a) Left insert onto the fovea capitis as described by Arai et al. [73]
cadaveric shoulder specimen (same specimen shown in (dashed arrow). (c) Coronal oblique T2-weighted fat-sup-
Fig. 5.1, viewed from anterosuperior), after the subscapu- pressed MR image of a 24-year-old man shows an intact
laris tendon was cut and reflected (thick arrows), shows the subscapularis tendon (thick arrows) inserting onto the top
articular side of the tendon. Both the superior glenohumeral two facets of the lesser tuberosity (LT). Greater tuberosity
ligament and superior-most subscapularis tendon insert onto (GT) is marked. (d) Coronal oblique T2-weighted fat-sup-
the fovea capitis of the humerus (black arrow). The rotator pressed MR image of a 46-year-old man shows a tear of
cable is less apparent than in Fig. 5.1 due to the far reflection subscapularis tendon, which involves the superior-most ten-
of the superior cuff. (b) Volume-rendered CT image of the don fibers and first two facet attachments. Tear is of full
left shoulder of a 34-year-old man demonstrates the four thickness at the first facet (disrupted from articular side
facets of the subscapularis footprint (F1-F4) as described by through lateral hood, thin arrows) and partial thickness at the
Yoo et al. [66] as well as superior-most tendon fibers which second facet (arrowhead)
suggested that the superior glenohumeral liga- studies that have evaluated the mean widths of
ment attaches to the tendinous slip of the sub- both supraspinatus and subscapularis tendon
scapularis instead [78]. footprints [48, 60, 66], a practical guideline is
Although prior authors have described the that the superior aspect of the subscapularis
footprint of the subscapularis to be shaped as a footprint should be approximately 25–40%
comma [48, 79] or the state of Nevada [74], a greater than the supraspinatus footprint. Using
study in 2015 [66] has found that the footprint is ultrasound, mean subscapularis tendon thick-
best evaluated from a three-dimensional perspec- ness has been described to be 4.4 mm in men
tive. In a cadaveric and clinical study, Yoo et al. and 3.8 mm in women [62].
described the three-dimensional footprint anat-
omy, which consists of four bony facets [66]. The
superior-most facet consists of approximately 5.2.5 Biceps Pulley
one-third of the entire footprint and the top two
facets consist of 60% of the entire footprint. The The biceps pulley (or reflection pulley) [32, 78,
third and fourth facets represent the so-called 80] is an important part of the rotator interval,
muscular insertion onto the surgical neck of the serving to maintain the position of the long head
humerus (Fig. 5.5b). of the biceps tendon, and the detailed anatomy is
Similar to the rest of the cuff, reported mean covered in Chap. 13. In brief, the pulley system is
dimensions of the footprint vary; however, a tendoligamentous sling, consisting of the cora-
based on cadaveric studies, the mean width cohumeral ligament (CHL), superior glenohu-
(medial-lateral dimension) ranges from 15 to meral ligament (SGHL), and fibers of the
26 mm and mean length (superior-inferior supraspinatus and subscapularis tendons
dimension) ranges from 18 to 24 mm [48, 60, (Fig. 5.6). As described above, the precise delin-
74, 79]. Yoo et al. [66] found a mean width of eation of the CHL and SGHL is debatable and
13.5 mm and a combined mean length of some experts advocate for the consideration of
51.5 mm; however their measurements were these ligaments as a single ligamentous structure
oblique relative to the standard imaging planes with variable parts rather than separate ligaments
used with imaging, and therefore cannot be [30, 32]. However, many other experts describe
directly compared using CT or MRI. Based on each structure individually.
a b c
Fig. 5.6 Normal and abnormal biceps pulleys. (a and b) fat-suppressed image shows a thick coracohumeral liga-
Reformatted sagittal-oblique MR arthrogram image from a ment (open arrow) with partial tearing of the superior gle-
T1-weighted fat-suppressed 3D-FSE acquisition shows a nohumeral ligament (dashed arrow), consistent with
normal biceps pulley, including a normal superior gleno- chronic injury. Improved visualization of these structures
humeral ligament (white arrows) and coracohumeral liga- is made possible due to the presence of a joint effusion and
ment (arrowheads). (c) Sagittal-oblique T2-weighted synovial proliferation in the subacromial-subdeltoid bursa
5.3 Pathologic Conditions firmed in patients at surgery or on imaging, which

may be due to inherent limitations with what is
This section describes the external (subacromial considered the reference standard. Partial-
and subcoracoid) and internal (posterosuperior and thickness tears typically begin 13–15 mm poste-
anterosuperior) impingement syndromes as well as rior to the biceps tendon, near the junction of the
their imaging manifestations. Subacromial, sub- supraspinatus and infraspinatus tendons [86].
coracoid, and anterosuperior impingement syn- The typical site of initiation in the medial-
dromes can affect adults of all ages while lateral dimension may vary depending on the
posterosuperior impingement is more common in type of partial-thickness tear. In a study of 12
young and middle-aged individuals involved in en bloc surgical specimens with bursal sided
repetitive overhead motions. By far the most com- tears, Fukuda et al.. found all the tears develop-
mon impingement syndrome is subacromial ing within 1 cm of the insertion, with nine
impingement. For this chapter, rotator cuff disease beginning slightly farther away from the inser-
is discussed together with subacromial impinge- tion [87]. In a similar study of 17 specimens
ment, although some degree of cuff disease is typi- with intra-substance tears, Fukuda et al. found
cally present in all of the impingement syndromes. 11 (65%) of the specimens with tears that
extended into the enthesis (insertion) [88]. To
our knowledge, a histological study document-
5.3.1 Rotator Cuff Disease ing the frequencies of articular sided tear initia-
and Subacromial tion sites in the medial-lateral dimension has
Impingement not been performed, but most authors consider
these tears to begin at [86] or near [89] the
5.3.1.1 Rotator Cuff Disease: Definition humeral insertion.
and Characterization The most commonly used classification of
Rotator cuff disease is an umbrella term that can partial-thickness tears is the Ellman classifica-
include calcific tendinitis, muscle tearing, or dis- tion, which characterizes the cuff based on the
orders involving the glenohumeral joint capsule assumption that an average intact cuff thickness
(adhesive capsulitis) or subacromial-subdeltoid is 10–12 mm [58]. Partial-thickness tears can be
bursa (tendinobursitis). However, in this chapter classified as low grade (grade 1, <3 mm deep),
we use the term rotator cuff disease to refer to moderate grade (grade 2, 3–6 mm deep), or high
tendinopathy and tendon tearing. At the histo- grade (grade 3, >6 mm deep). The natural his-
logic level, tendinosis is characterized by micro- tory of partial-thickness cuff tears is not well
scopic collagen fiber disruption, a decrease in understood and some authors have found low
type I collagen, glycosaminoglycan accumula- rates of tear progression; however there is bio-
tion, and an increase in water content [81–83]. mechanical evidence to support repair of tears
Tendon tears are macroscopically evident, involving greater than 50% of the tendon [90].
either by gross inspection or by imaging. Partial- Based on available data, tears that involve less
thickness tears can be classified into articular than 50% of the tendon can be debrided with
sided, bursal sided, or intra-substance tears (also good results [91].
referred to as interstitial, intratendinous, or con- Full-thickness tendon tears allow communica-
cealed tears). It is generally agreed upon that tion between the glenohumeral joint and
articular sided tears are at least twice as common subacromial-subdeltoid bursa. A full-thickness tear
as bursal sided tears [58, 84] and both have been can be pinhole in size or involve an entire tendon
associated with shoulder impingement syndromes (which is referred to as a full-thickness, full-width
[8]. Cadaveric studies have shown pure intra-sub- tendon tear). Compared with partial- thickness
stance tears to be twice as common as articular tears, full-thickness tears are associated with more
sided tears [85]; however this has not been con- synovial inflammation and tendon degeneration
[92]. Full-thickness tears of the supraspinatus and have proposed abandoning the term altogether and
infraspinatus tendons can be classified based on instead using the term subacromial pain syndrome
shape at the time of surgery [93] or on preoperative [108] or rotator cuff disease [109], or simply
MRI [94], although one study found limited con- describing tendinosis or tears of the rotator cuff
cordance for L-shaped tears [95]. A practical [110]. However, the term impingement syndrome
method of reporting is to describe the tendons remains commonly used in practice and is recog-
involved and to measure the anterior-posterior and nized as a disease in the tenth revision of the
medial-lateral (retraction) dimensions of the tear International Statistical Classification of Diseases
[96]. Some authors define massive cuff tears as and Related Health Problems (ICD) published by
full-thickness tears that are greater than 5 cm in the the World Health Organization.
largest dimension and involve two or more rotator Much of the controversy behind the term
cuff tendons [97, 98]. Of note, measurement preci- stems from authors who differ in their belief of
sion can be limited in the setting of markedly the relative importance of the factors involved in
degenerated tissue edges, even at surgery [99]. rotator cuff disease. In 1972, Charles Neer intro-
Delamination of the cuff, defined as intratendinous duced the concept of impingement syndrome in
horizontal splitting between the articular and bursal his landmark article which included 100 cadav-
layers, is common and estimated to be approxi- eric scapulae and 46 patients [111]. He suggested
mately 56% on non-contrast MRI exams [100]. that rotator cuff disease resulted from impinge-
The presence of delamination should be detected ment from the anterior one-third of the acromion,
on imaging since it can be missed during routine coracoacromial ligament, and acromioclavicular
arthroscopy and result in lower healing rates if joint on the supraspinatus tendon, sometimes
untreated [101]. extending onto the anterior infraspinatus tendon
Changes in muscle volume can be seen in rota- and long head of the biceps tendon. The belief
tor cuff disease, particularly with chronic tendon that extrinsic compression was the primary cause
tears, likely due to a combination of mechanical of rotator cuff tendon disease led to the use of the
unloading [102] and denervation [103]. Although term impingement syndrome to be synonymous
part of the same process, fatty infiltration and with rotator cuff disease in general [109].
muscle atrophy have been shown to be indepen- However, we now know that rotator cuff disease
dent predictors of functional outcome after repair can be asymptomatic and therefore labeling all
[104]. Fatty infiltration and muscle atrophy can be tendon abnormalities as impingement syndrome
readily detected on CT, ultrasound, and MRI. Both would be inappropriate. In addition, using
of these processes are important [105, 106], but a dynamic ultrasound and MRI, authors have
complete discussion of muscle disease is beyond shown that asymptomatic contact can occur
the scope of this chapter. between the intact rotator cuff and the acromion,
coracoacromial ligament, and acromioclavicular
5.3.1.2 External Subacromial joint, which is felt to be physiologic [112, 113].
Impingement Syndrome: Contact alone cannot be labeled as impingement
Definition and Associations syndrome since, by a common definition, pain
The term impingement syndrome can be defined as must be present.
a painful, localized compression of the rotator cuff It is now widely recognized that the patho-
tendon [107]. The most common subtype of the physiologic cause of rotator cuff disease is multi-
shoulder impingement syndromes is external sub- factorial, although the relative importance of
acromial impingement, which refers to compres- each component remains debated. Regardless of
sion of the rotator cuff by the coracoacromial arch whether or not contact between the cuff and
above and the humerus below. There exist so many extrinsic structures is causative (primary) or sec-
different uses of the term subacromial impinge- ondarily involved, after the rotator cuff tendon
ment syndrome in the literature that several authors becomes diseased, nociceptive units in tendon,
bursa, and subchondral bone become sensitized anatomic characteristic [129], whereas others
[114, 115] and physiologic contact forces can have found it to be an age-dependent acquired
induce pain. This is supported by a study from characteristic [130, 131]. Many authors have
Gellhorn et al. in 2015, who utilized intense found associations of Bigliani type III acromion
focused ultrasound and were not able to elicit morphology with cuff degeneration and tearing
sensation in a control group, but in patients with [122, 123, 132–137]. In addition some authors
rotator cuff disease sensations were elicited in the have found associations of cuff disease with acro-
cuff, subacromial bursa, and subchondral bone at mial slope in the sagittal [138, 139] or coronal
intensities less than half of what was used in the planes [18, 139, 140], whereas others have not
control group [116]. [17]. Previous reports have suggested that scapu-
An abundance of literature has demonstrated lar dyskinesia was involved in the pathogenesis
many associations between rotator cuff disease of impingement syndrome [141]; however a sys-
and extrinsic structures, including congenital and tematic review by Ratcliffe et al. in 2014 demon-
developmental variants in bone and soft-tissue strated that there is insufficient evidence to
shape, acquired and often degenerative bone support this [142].
production, as well as os acromiale. The reader Inferiorly directed osteophytes from the acro-
should be aware that statistically significant asso- mioclavicular joint have also been associated
ciation is insufficient to establish causality with- with rotator cuff tears [143–145]. Many studies
out evidence of direction of influence. However, have advocated for arthroscopic distal clavicular
despite the continued controversy of causation, resection in the presence of rotator cuff patholo-
most practitioners would agree that it is impor- gies, although nearly all were level IV evidence
tant to be aware of lesions that have been associ- [146–153]. Randomized, controlled trials (level I
ated with rotator cuff disease. evidence) published in 2014 [154] and 2015
Neer described proliferative spurs which were [155] found that arthroscopic distal clavicular
frequently present in cases of impingement, and resection did not result in better clinical or struc-
when anterolateral acromioplasty and coracoac- tural outcomes compared with rotator cuff repair
romial ligament release were performed, patient alone. In addition, distal clavicular resection can
satisfaction and relief of pain were achieved lead to symptomatic acromioclavicular joint
[111]. Subsequent literature has shown that the instability [154]. However, arthroscopic distal
proliferative spurs described by Neer represent clavicular resection is still frequently performed
coracoacromial enthesophytes [88, 117, 118] and therefore radiologists should make note of
(Fig. 5.7). Coracoacromial enthesophytes as well large osteophytes when present.
as lateral deltoid enthesophytes have been associ- Anatomic studies have also focused on the
ated with full-thickness cuff tears in symptomatic coracoacromial ligament and its role in impinge-
patients [119]. ment. The CAL can have a variety of shapes
Bigliani et al. [120] proposed a classification including a Y-, V-, quadrangular, broad band, and
of acromial morphology: type I, flat; type II, multi-banded configurations [156, 157].
curved; and type III, hooked. Classification of Subacromial enthesophytes preferentially form
acromial morphology is controversial with sev- at the anterolateral aspect of the CAL [158].
eral investigators showing poor reliability using Additionally, CAL morphologies that demon-
radiographs [121–127]. This may arise from dif- strate more than one band have been associated
ferences in projection angle or confusion in ter- with rotator cuff degeneration [156]. Although
minology and misclassification of type I and II some authors have advocated for coracoacromial
acromions with subacromial enthesophytes as ligament release, either alone or in combination
type III acromions [128]. These differences may with other procedures [159–162], biomechanical
explain the vastly conflicting results of some stud- studies have suggested that the ligament is an
ies. For instance, Nicholson et al. found that acro- important restraint to superior subluxation of the
mial morphology is an age-independent, primary humeral head [163].
a b
c d
Fig. 5.7 Subacromial enthesophytes associated with natus and partial-thickness tearing of the biceps tendon
rotator cuff disease and external subacromial impinge- (not shown). (c and d) AP radiograph and coronal oblique
ment in a 62-year-old man (a and b) and a 60-year-old T1-weighted MR image show subacromial (thin arrows)
man (c and d). (a and b) Supraspinatus outlet radiograph and greater tuberosity (open arrows) enthesophytes,
and sagittal-oblique T1-weighted MR image show a large which were associated with rotator cuff and biceps tendon
subacromial enthesophyte (thin arrows), which was asso- disease (not shown). Acromioclavicular joint osteoarthro-
ciated with a full-thickness full-width tear of the supraspi- sis is present (arrowhead)
Os acromiale results from failure of fusion of meso-acromion, and pre-acromion. The type of
the anterior acromion during development and os acromiale is defined by the unfused segment
has been associated with impingement syndromes immediately anterior to the site of nonunion
and rotator cuff disease [164, 165]. A meta-analy- (Fig. 5.8). The os meso-acromiale subtype is most
sis in 2014 pooled data from 26 articles reported common (failed fusion between the meta-
a 7% crude prevalence of os acromiale [166]. The acromial and meso-acromial ossification centers)
acromial apophysis is composed of four ossifica- (Fig. 5.8a, b) [129, 164, 167]. Pain can arise from
tion centers: basi-acromion, meta- acromion, the nonunion site itself or from dynamic impinge-
a b
c d
Fig. 5.8 Os acromiale variants in three different patients. addition, there is superior subluxation of the humerus
(a and b) Coronal oblique and axial T1-weighted fat- with contrast extending into an unstable os meso-
suppressed MR images after contrast injection into the acromiale (open arrow). (c) Sagittal-oblique T1-weighted
glenohumeral joint show communication with the MR image shows an os pre-acromiale (arrowhead). (d)
subacromial-subdeltoid bursa through a retracted, full- Axial gradient fat-suppressed MR image shows an os
thickness supraspinatus tendon tear (dashed arrow). In meta-acromiale with degenerative changes (arrow)
ment, whereby deltoid contraction during arm graphic protocols vary, but all radiographic
elevation narrows the cuff outlet [168]. shoulder studies should include a frontal radio-
graph, which can either be an anteroposterior
5.3.1.3 Radiographic and CT Findings (AP) projection with the humerus in neutral,
Radiography is the most appropriate initial imag- internal, or external rotation or be a Grashey pro-
ing modality for evaluation of shoulder pain of jection, which is in the plane of the scapula.
any etiology [169]. Calcium hydroxyapatite Although radiographs cannot directly visualize
deposition, fractures, acromioclavicular osteoar- the rotator cuff, the acromiohumeral distance has
throsis, and glenohumeral osteoarthrosis can be been used to indirectly evaluate the tendon. A sys-
readily diagnosed with radiographs. Local radio- tematic review in 2015 has questioned the reliability
of this measurement on radiographs, particularly also demonstrate acromial morphology and sub-
using non-standardized techniques [170]. Despite acromial enthesophytes (Fig. 5.7a) [191].
this, the acromiohumeral distance continues to be Fluoroscopy has a limited role in the evaluation
used in general practice. A measurement of less of patients with cuff disease, but may help iden-
than 6–7 mm has been reported to be a specific sign tify subacromial enthesophytes [192] and may be
of a full-thickness cuff tear [171] and the amount of useful for directing injections.
reduced distance is correlated with the size of the An os acromiale can be detected on radio-
tear [172, 173]. More recently, Goutallier et al. sug- graphs, with a higher sensitivity using the axillary
gested that an AHD of less than 6 mm almost sys- radiograph compared with the AP view or the
tematically involves a full-thickness, full-width, or supraspinatus outlet view (73.5%) [193].
near-full-width tear of the infraspinatus tendon with Familiarity with the appearance of the overlapping
advanced fatty degeneration, and is not amenable to shadows of the os acromiale and remaining acro-
surgical repair [174]. mion on the AP and supraspinatus outlet views can
Osseous changes near the tuberosities of the facilitate detection [193]. Despite this, a meta-
humerus have also been reported to be associated analysis in 2014 demonstrated that crude radio-
with cuff disease. Most but not all [175] studies logical prevalence (4.2%) was less than half of the
have found an association between intraosseous true anatomical prevalence (9.6%), confirming the
cystic changes near the superior facet of the suboptimal sensitivity of radiographs [166].
greater tuberosity and cuff disease [176–180]. Computed tomography (CT) arthrography has
Similarly, most but not all [178] studies have also been used for evaluation of the rotator cuff,
found the same association for cysts near the particularly when MR imaging is contraindi-
lesser tuberosity [181–183]. However, more pos- cated. For evaluation of full-thickness tears of the
teriorly located cysts near the bare area generally supraspinatus and infraspinatus tendons, sensi-
have not shown an association with cuff disease tivity and specificity of CT arthrography have
[176, 177, 184] and have been considered a nor- been reported to be similar to those of MR
mal variant by some authors [185]. arthrography [194, 195]. However, sensitivity for
The association of enthesophytes, cortical subscapularis tendon tear detection has been
thickening, and subcortical sclerosis at the tuber- shown to be lower compared with the other cuff
osities and cuff disease is less well established. tendons when evaluated with CT arthrography
There are conflicting results in the literature with [194, 196, 197]. In addition, CT arthrography
some authors finding an association between with intra-articular contrast is less sensitive than
enthesophyte formation/subcortical sclerosis at MRI for partial-thickness tears, especially bursal
the greater tuberosity, and rotator cuff disease sided tears [194, 195].
(Fig. 5.7c, d) [175, 186] whereas others have found
no association [187]. Koh et al. reported that the 5.3.1.4 Ultrasound Findings
Grashey view is more sensitive than conventional Ultrasound technique and findings of the normal
AP view for the detection of greater tuberosity and abnormal rotator cuff are covered in the
enthesophytes, cysts, and sclerosis [186]. Sonographic Evaluation of the Shoulder chapter.
A subacromial enthesophyte is a highly spe- A meta-analysis by Roy et al. in 2015 has found
cific but late radiographic finding of external sub- that ultrasound demonstrates comparable diag-
acromial impingement (Fig. 5.7) [188–190]. To nostic accuracy to MRI and MR arthrography for
improve detection of a subacromial entheso- the characterization of full-thickness cuff tears
phyte, the AP projection can be modified with with overall sensitivity and specificity estimates
30-degree caudal angulation of the beam [189, greater than 90% [198]. As for the diagnosis of
191]. The supraspinatus outlet view (also known partial tears and tendinopathy on ultrasound, esti-
as the modified trans-scapular lateral or Y- views) mates for specificity were high (94%), but sensi-
is obtained at 5–10° of caudal angulation and can tivity was lower (68% for partial tears and 79%
for tendinopathy). When considering accuracy, mum [207]. This is known as the magic angle
cost, and safety, the authors concluded that ultra-effect [208] and up to a sixfold change in signal
sound was the best option [198]. When greater intensity has been shown in histologically normal
tuberosity irregularities are detected on ultra- regions of the rotator cuff tendon at 3 T depend-
sound, the operator should have a high index of ing on orientation [27]. Furthermore, the rotator
suspicion for rotator cuff tearing since this find-cuff is composed of distinct tendons that course
ing has been shown to be a reliable indicator in different orientations. For instance, at the
[199]. superior facet of the greater tuberosity, the pre-
Dynamic assessment of the rotator cuff and dominant orientation of the supraspinatus is
surrounding structures can also be performed medial to lateral whereas the predominant orien-
with ultrasound. Dynamic imaging signs that tation of the anterior infraspinatus tendon fibers
have been associated with subacromial impinge- is anterior to posterior. This can result in different
ment include increased thickness (also referred signal intensities of the individual contributions
as gathering or bunching) of the subacromial- to the cuff [26, 27, 67].
subdeltoid bursa [200, 201] or supraspinatus ten- However, not all increases in intratendinous
don [201] lateral to the coracoacromial arch signal are artifactual and MRI-histology correla-
during arm abduction. Less commonly, upward tion studies have shown that signal increases and
migration of the humeral head during active ele- increased thickness of the cuff tendon can corre-
vation of the arm prevents passage of the greater late with histologically determined tendinosis
tuberosity and cuff beneath the acromion [201]. [209, 210]. A practical approach for the diagnosis
Other authors have found that thickening of the of tendinosis is to rely on the combined findings
bursa during abduction is a less useful sign for of increased signal intensity within the cuff with-
impingement since it may be seen to a similar out extension to the articular or bursal surfaces as
degree in healthy volunteers [202] and may be well as swelling, or increased thickness of the
negative in approximately 20% of patients with tendon [211]. The signal intensity abnormality
impingement [203]. Patient pain during dynamic should be less than that of fluid. Additionally, in
maneuvers should be noted since diagnostic the setting of increased signal without tendon
accuracy for impingement is increased when caliber change, recognizing the usual location of
both objective ultrasound signs and subjective the magic angle effect in the adducted shoulder
pain are simultaneously present [204, 205]. (downsloping region) can prevent false-positive
diagnoses [211]. Sein et al. found excellent intra-
5.3.1.5 MR Findings observer reliability for the grading of MRI-
There are limited studies evaluating the accuracy determined supraspinatus tendinosis at 1.5 T
of diagnosing tendinosis on MRI. This is largely (intraclass correlation coefficient, ICC, 0.85), but
due to the complex structure as well as the orien- only fair to good inter-observer reliability (ICC,
tation of the rotator cuff. On MRI, tendinosis of 0.55). At 3 T, Bauer et al. found excellent intra-
cylindrical tendons such as the Achilles is diag- observer reliability (kappa, 0.84–0.93) and
nosed by the presence of increased signal inten- moderate- to-good inter-observer reliability
sity [206]. However, unlike the Achilles tendon (kappa, 0.55–0.74) [212].
which demonstrates parallel orientation to the Partial-thickness tears of the rotator cuff can
main magnetic field (B0) through its course, the be diagnosed when there is signal abnormality
superior rotator cuff tendon makes a near-90- extending to a surface of the cuff, approaching
degree turn as it originates from the muscle and the intensity of fluid. Increased linear fluid-signal
inserts onto the greater tuberosity. It is well intensity that extends along the long axis of the
known that as collagen fiber orientation tendon can represent a partial-thickness intra-
approaches 54.7° relative to the main magnetic substance tear [34] or delamination when there is
field, frequency changes from dipolar interac- communication with the bursal or articular sur-
tions are minimized and signal intensity is maxi- faces. The accuracy of MRI for partial-thickness
cuff tears is lower than that for full-thickness cuff lished to date. However, the concept of subcora-
tears, and meta-analyses have found standard coid impingement has been recognized for over a
MRI to demonstrate 64–67% sensitivity and century [223].
92–94% specificity and direct MR arthrography External subcoracoid impingement may be
to demonstrate 83–86% sensitivity and 93–96% due to idiopathic, iatrogenic, or traumatic causes.
specificity [198, 213]. Pitfalls for the diagnosis of Idiopathic causes include anatomic variations,
a partial-thickness tear include volume averaging such as a long coracoid process, protuberant
for small tears due to a low ratio between tear lesser tuberosity, or space-occupying lesions
size and voxel size as well as fibrovascular tissue including ganglion cysts and heterotopic ossifica-
residing in the tear, both of which will cause sig- tion [220, 222, 224–228]. Iatrogenic causes
nal intensity to be less than that of fluid. A unique include surgical procedures such as coracoid
partial-thickness bursal sided tear involves the transfer, posterior glenoid osteotomy, or acromi-
transverse head of the infraspinatus tendon, onectomy [220]. Posttraumatic causes can be due
which can be avulsed and retracted from the to fractures of the scapula, including the coracoid
oblique portion [26, 63]. process, glenoid or neck, or proximal humerus
Full-thickness tears of the rotator cuff typi- [220]. Furthermore, anterior glenohumeral insta-
cally demonstrate a fluid signal intensity defect bility can also cause narrowing of the coracohu-
[214]. MRI is very accurate for full-thickness meral distance [229, 230].
cuff tears with meta-analyses showing 90–92% The diagnosis of subcoracoid impingement is
sensitivity and 93% specificity for standard MRI challenging. Symptoms are described as dull,
and 90–95% sensitivity and 95–99% specificity anterior shoulder pain aggravated by forward
with direct MR arthrography [198, 213]. For the flexion and internal rotation [220]. The most
diagnosis of partial- or full-thickness tendon common findings reported on imaging include
tears using indirect MR arthrography, studies subscapularis tendon disease (either bursal sided
have shown comparable sensitivity, specificity, or articular sided [8]) and/or narrowing of the
and accuracy with direct MR arthrography [215, coracohumeral interval, which is the space
216]. In addition, a study in 2014 has suggested between the coracoid process and anterior
that a single 3D T1-weighted FSE sequence is humerus.
comparable to conventional 2D sequences [217].
5.3.2.2 Radiographic and CT Findings
Radiographs may demonstrate a far laterally pro-
5.3.2 External Subcoracoid jecting or a chevron-shaped coracoid process on
Impingement the AP or supraspinatus outlet views, respectively
[231, 232]. Axillary views have not been reported
5.3.2.1 Definition to be helpful for diagnosis [233]. Cystic changes
External subcoracoid impingement (also known near the lesser tuberosity may be present [233].
as coracoid impingement) is an uncommon cause The coracoid index was first described on CT,
of anterior shoulder pain, resulting from impinge- defined as the lateral projection of the coracoid
ment of the subscapularis or biceps tendon process beyond the glenoid joint line [233]. Dines
between the coracoid process and lesser tuberos- et al. reported a mean value of 8.2 mm (range—
ity [218–221]. Unfortunately a literature review 2.5 to 25 mm) in healthy shoulders and an index
by Martetschlager et al. [222] in 2011 found that of 23.5 mm in one of their patients [233]. The
our knowledge of subcoracoid impingement is coracohumeral interval has also been measured
not supported by rigorous scientific studies, espe- on CT. In healthy shoulders, Gerber et al. reported
cially with regard to diagnosis, physical exami- a mean value of 8.7 mm for an adducted arm and
nation, imaging, treatment options, and expected 6.8 mm for the arm in flexion and internal rotation,
outcomes. In fact, there have been no prospective concluding that subcoracoid impingement was
randomized trials or comparative studies pub- more likely during forward flexion of a shoulder
a b
Fig. 5.9 67-year-old man with left shoulder pain. (a and (arrowhead). There is a narrowed coracohumeral interval,
b) Axial intermediate-weighted MR images show a high- measuring 5 mm, with cystic changes within the lesser
grade partial-thickness tear of the subscapularis tendon tuberosity. Subcoracoid and subacromial-subdeltoid bur-
involving the articular side and lateral hood (arrow). The sitis is present. Subcoracoid impingement was raised
biceps tendon is also partially torn and medially subluxed which was clinically confirmed
with a far laterally projecting coracoid tip close to 5.3.2.4 MR Findings
the scapular neck [234]. Masala et al. also found Several investigators have reported on coracohu-
that CT was useful for the measurement of the meral intervals as measured on MRI [8, 238–245]
coracohumeral interval and was sensitive to even (Fig. 5.9). Although previous authors have found
slight bone changes [235]. Abnormal coracohu- statistically significant differences in mean val-
meral interval values have been described on MRI ues between individuals with and without sub-
and subsequently adopted to CT, although to date coracoid impingement, no ideal cutoff value
there are no studies correlating measurements exists with high sensitivity and specificity [241].
made between the two modalities. However, in patients clinically suspected to have
subcoracoid impingement, a value of 6 mm or
5.3.2.3 Ultrasound Findings less has been used to be consistent with the dis-
Tracy et al. performed sonography on asymptom- ease [8, 241–244].
atic volunteers and patients with the clinical diag- Associated subscapularis tendon disease can
nosis of subcoracoid impingement. Using a linear be diagnosed on MRI. Partial-thickness tendon
array transducer with the arm adducted across the tears can be articular sided, bursal sided (involv-
chest, mean coracohumeral distance was ing the anterior surface), or intra-substance (also
12.2 mm (range 7.8–17.5 mm) for the volunteers called interstitial delamination [246] or a con-
and 7.9 mm (range 5.9–9.6 mm) for the patients. cealed lesion [66]). Full-thickness tears demon-
In addition, in patients with subcoracoid impinge- strate a focus of complete tendon discontinuity
ment, bursal thickening in the subcoracoid region [247], which can either extend from the articular
can be seen which can cause an anterior snapping side to the bursal side or extend from the articular
sensation visible on dynamic sonography [236, side to the lateral edge of the tendon (also termed
237]. As described above, ultrasound is also use- the lateral hood or lateral end [66]) when involv-
ful for the diagnosis of subscapularis tendon dis- ing the footprint (Fig. 5.5d). Several classifica-
ease, including tendinosis. tions of subscapularis tendon tears exist, including
the LaFosse [248], Fox and Romeo [249], and the explains the mechanism of most articular sided
Yoo classifications [66]. However, similar to the tears of the superior rotator cuff and those who
superior cuff, a practical method is to describe believe that it explains only a minority of them.
partial- or full-thickness involvement and the In 1992, Walch et al. proposed that repetitive,
location of the tear, and provide measurements in forceful contact leads to cuff tearing in throwing
the superior-inferior and medial-lateral (retrac- athletes [255, 259]. Subsequent authors sup-
tion) directions. Involvement of the inferior, extra- ported this view for several years, although there
articular portion of the tendon (so-called muscular was disagreement about the anterior capsuloliga-
attachment) or tears of the myotendinous portions mentous structures in the disabled throwing
should be described since these may influence the shoulder [256, 257]. Some believed that the pres-
decision for an open rather than arthroscopic ence of anterior instability worsened internal
approach for repair [250]. impingement [256, 260, 261], whereas others
Combined full-thickness tears that involve the believed that instability was not a typical part of
subscapularis and supraspinatus tendons are the pathology in the throwing shoulder [257].
referred to as anterosuperior rotator cuff tears Burkhart et al., in a series of articles published in
[251], and have been associated with combined 2003, summarized the literature and proposed a
subcoracoid and subacromial impingement pathologic cascade in the throwing shoulder,
[242]. The retracted edges of the two tendons can beginning with acquired posteroinferior capsular
be connected by a bridge of connective tissue contracture [262]. This results in a posterosupe-
which has been described to represent the cora- rior shift of the glenohumeral contact point dur-
cohumeral ligament [25, 32, 252]. This tissue has ing the late cocking phase, allowing hyper-external
been called the “comma sign” [253] at surgery or rotation of the humerus due to reduced camming
the “bridging sign” on MRI [254] and may be effect, but causing peel-back forces which could
thickened to various degrees. Recognition of this lead to a SLAP lesion. Burkhart theorized that
sign is useful to avoid misdiagnosing an intact cuff failure in throwing athletes was typically due
subscapularis tendon [254] or a medially dislo- to repetitive tensile and torsional loading rather
cated long head of the biceps tendon. than impingement, although cuff tearing due to
internal impingement could be seen in pitchers
who hyper-externally rotate their arms in excess
5.3.3 Internal Posterosuperior of 130° during the late cocking phase [262, 263].
Impingement Unfortunately, there is no consensus of the
causative pathophysiologic process of the dis-
5.3.3.1 Definition abled throwing shoulder. In the literature, there
The term posterosuperior impingement is typi- are several imaging findings that have been asso-
cally, but not always, used in association with the ciated with posterosuperior impingement and the
throwing shoulder [255, 256]. Similar to external disabled throwing shoulder. However, it should
subacromial impingement, the term and concept be emphasized that the use of the term posterosu-
of posterosuperior impingement are controversial. perior impingement differs between individual
It is generally accepted that there is physiologic physicians and practices. The radiologist is urged
contact of the undersurface of the cuff against the to reconcile their nomenclature with their refer-
edge of the glenoid in the abducted, externally ring physicians.
rotated position [257, 258]. Furthermore, it is
generally accepted that posterosuperior impinge- 5.3.3.2 Radiographic and CT Findings
ment can cause articular sided tears of the supe- In patients diagnosed with posterosuperior inter-
rior rotator cuff in throwing athletes. However, nal impingement, cystic changes of the greater
there are two different views of posterosuperior tuberosity may be seen on radiographs in approx-
impingement in the literature with regard to imately half [264], although similar findings have
throwing athletes: those who believe that it also been reported in 39% of asymptomatic
professional baseball pitchers [265]. Remodeling found that direct MR arthrography appears mar-
of the posterior glenoid rim can also be seen ginally superior to standard MRI with higher
radiographically, although cross-sectional imag- sensitivity (83 vs. 79%, respectively) and speci-
ing would optimally evaluate this region [264]. ficity (93 vs. 87%) [275, 276]. In pitchers with
Bennett lesions, which are described as miner- glenohumeral internal rotation deficits, poste-
alization near the posteroinferior glenoid rim, rior capsular fibrosis may be evident on MR
have been defined exclusively in baseball arthrography [277]. Tuite et al. found a tendency
pitchers, although they are seen in approximately for a thicker posteroinferior labrum and shal-
22% of asymptomatic major league baseball lower capsular recess in overhead throwing ath-
pitchers [265–267]. Bennett lesions are theorized letes with internal impingement and internal
to be caused by traction on the posterior band of rotation deficit compared with controls using
the inferior glenohumeral ligament and may also the standard, adducted MRI position [278].
be identified on CT [268, 269]. The abducted and externally rotated (ABER)
position may be helpful to detect delamination
5.3.3.3 Ultrasound Findings of the rotator cuff tendon (Fig. 5.10d) and for
As described above, ultrasound is sensitive for increased accuracy for diagnosis of labral
partial-thickness articular sided tears of the rota- lesions [279–281], although it adds an extra
tor cuff. In patients diagnosed with posterosupe- 5–10 min to the examination due to necessary
rior internal impingement, ultrasound may patient repositioning and coil changes. As
demonstrate cortical irregularity of the postero- described above, physiologic contact between
lateral humeral head region [270]. In addition, the undersurface of the rotator cuff and postero-
posterosuperior labral detachment or tears may superior glenoid in the ABER position is con-
be seen, characterized as an anechoic or sidered physiologic [257].
hypoechoic cleft between the labrum and glenoid
or within the labral substance, respectively. This
may be emphasized with dynamic ultrasound and 5.3.4 Internal Anterosuperior
may be associated with paralabral ganglion cysts Impingement
[270]. Posterior capsular thickening may be asso-
ciated with the diagnosis of internal impingement 5.3.4.1 Definition
and can be measured with ultrasound [271]. Anterosuperior impingement is less well defined
compared with the previously discussed entities.
5.3.3.4 MR Findings This entity was first described in 2000 by Gerber
Direct MR arthrography is most useful for eval- and Sebesta in 16 patients, nearly all of whom
uation of the constellation of imaging findings were involved with regular overhead activity,
associated with posterosuperior internal most during their profession as manual laborers
impingement, which includes cystic changes [282]. The authors postulated that repetitive con-
near the posterolateral humeral head, partial- tact of the superior subscapularis tendon and
thickness articular sided tears of the infraspina- biceps pulley against the anterosuperior glenoid
tus and posterior supraspinatus tendons, and rim caused damage to these structures since pain
posterosuperior labral lesions [272–274] could be reproduced when the arm was horizon-
(Fig. 5.10). For partial- thickness cuff tears, tally adducted, internally rotated, and positioned
meta-analyses have found that direct MR with various degrees of anterior elevation [282].
arthrography is slightly superior to standard In 2002, Struhl reported on ten nonathletic
MRI with a higher range of sensitivity (83–86% patients who demonstrated partial-thickness artic-
vs. 64–67%, respectively), but comparable ular sided tears of the supraspinatus tendon which
specificity (93–96% vs. 92–94%, respectively) appeared to be compressed between the humeral
[198, 213]. For labral tears, meta-analyses have head and the anterosuperior labrum [283]. Struhl
a b
c d
Fig. 5.10 MR arthrogram images of a 30-year-old major marked irregularity at the greater tuberosity (thick arrow).
league baseball pitcher with shoulder pain. (a) Coronal (c) Sagittal intermediate-weighted fat-suppressed image
intermediate-weighted fat-suppressed image shows a confirms cystic changes near the posterosuperior aspect
high-grade, partial-thickness, articular sided tear at the of the humeral head with adjacent articular sided tearing
footprint of the supraspinatus-infraspinatus tendon junc- of the infraspinatus tendon. (d) ABER view improves
tion (arrow). A posterosuperior labral tear is present delineation of the extent of medial delamination (arrow).
(arrowhead). (b) Axial T1-weighted fat-suppressed The same posterosuperior humeral head cyst is seen
image confirms labral tear (arrowhead) and shows (dashed arrow)
stated that contact of the cuff and superior labrum consistent with the entity of anterior internal
was normal in the intact shoulder, but abnormal in impingement. Subsequent authors have inter-
the setting of cuff tears. Nearly all his patients had preted his study to refer to anterosuperior internal
identical clinical presentations to subacromial impingement [284, 285]. Notably, Struhl did not
impingement, but the arthroscopic findings were diagnose biceps pulley lesions in any of his
patients and in only two of the ten cases was a study [284], subsequent cadaveric and in vivo
subscapularis tendon tear present [283]. MRI studies have shown that contact between the
In 2004, Habermeyer defined anterosuperior subscapularis tendon and glenoid rim typically
impingement as the presence of an anterosuperior occurs during the Hawkins position (90-degree
labral lesion and positive impingement of the sub- forward elevation and maximal internal rotation)
scapularis tendon between the lesser tuberosity [287, 288]. Finally, authors have noted that anter-
and anterosuperior glenoid rim in the flexed, hori- osuperior impingement tests may be negative in
zontally adducted, and internally rotated position patients with pulley lesions, suggesting that
during arthroscopy [284]. He included 89 patients, anterosuperior impingement is not the only
none of whom performed regular overhead activ- pathomechanism for pulley lesions [289].
ity, but all with surgically confirmed pulley
lesions. Notably he excluded patients with com- 5.3.4.2 Imaging Findings
plete tears of the supraspinatus or subscapularis As described above, there are no pathognomonic
tendons. He found that the presence of anterosu- lesions for the diagnosis of anterosuperior
perior impingement increased when a partial- impingement. However, several articles have
thickness articular sided tear of the subscapularis focused on the biceps pulley, and in particular the
tendon was present. Habermeyer proposed a clas- superior glenohumeral ligament [284, 290].
sification scheme and outlined the pathologic cas- Habermeyer [284] described a surgical classifica-
cade, which begins with a degenerative or tion scheme for intra-articular lesions associated
traumatic tear of the biceps pulley [284]. During with anterosuperior impingement which has been
the anterosuperior impingement position, the long adopted to MR arthrography: group 1 lesions
head of the biceps tendon medially subluxates and involve the superior glenohumeral ligament
causes a tear of the subscapularis tendon. Due to a (SGHL), group 2 lesions involve the SGHL with
lack of dynamic soft-tissue restraints, the humeral partial-thickness articular sided supraspinatus
head migrates anterosuperiorly, impinging against tendon tears, group 3 lesions involve the SGHL
the glenoid rim and causing the entity of anterosu- with partial-thickness articular sided subscapu-
perior impingement [284]. laris tendon tears, and group 4 lesions involve the
The diagnosis of anterosuperior impingement SGHL with both partial-thickness articular sided
is very challenging and there are only a handful supraspinatus and subscapularis tendon tears.
of scientific articles from which to draw conclu- Diagnosis of SGHL abnormalities can be read-
sions. First, there is no patient population that is ily made with MR arthrography [77, 291], or in the
typically affected. Anterosuperior impingement presence of a joint effusion (Figs. 5.6c and 5.11a).
has been diagnosed in young and elderly patients The biceps tendon may be subluxed, dislocated,
[282, 284]. Additionally, patients may be regu- and torn to various degrees [284]. Subscapularis
larly engaged in overhead activities [282] or not tendon tears are usually visible to some degree in
[284], or may even be wheelchair bound [272, all three standard imaging planes, including coro-
286]. Second, clinical tests have not been reported nal oblique (Fig. 5.5), sagittal oblique [290], and
to be sensitive or specific for this entity [283, axial (Fig. 5.9) [292] planes and all three should be
285]. Third, the existing literature does not sup- used for complete evaluation. According to
port a mandatory lesion. The pulley system was Habermeyer’s theory, an unstable biceps tendon
surgically intact in 3 of the 16 patients in Gerber causes the subscapularis tendon to tear, and these
and Sebesta’s study [282] and in presumably would invariably involve the superior-most fibers
most of the patients in Struhl’s study [283]. (Fig. 5.11). However, it should be reinforced that
Furthermore, anterosuperior impingement has full-thickness tears of the subscapularis tendon are
been diagnosed in many patients without sub- excluded in Habermeyer’s classification Scheme
scapularis tendon lesions [283, 284]. Fourth, [284], although they may be seen in later stages of
although used as a criterion in Habermeyer’s the disease.
a b c
Fig. 5.11 53-year-old woman with shoulder pain during pressed images including at the level of the superior edge of
elevation and internal rotation of the arm. (a) Sagittal- the subscapularis tendon (b) show tendon tearing involving
oblique intermediate-weighted fat-suppressed image shows the superior-most fibers of the subscapularis at the lateral
a tear of the superior glenohumeral ligament (arrow) and hood with delamination (thick arrow). The partially torn
partial tearing of the long head of the biceps tendon (arrow- long head of the biceps tendon is medially subluxed (arrow-
head). Subacromial-subdeltoid and subcoracoid bursitis is head). Anterosuperior impingement was suggested based
present. (b and c) Axial intermediate- weighted fat-sup- on imaging, and confirmed by the orthopedic surgeon
5.4 Postoperative Imaging thickness tendon tears can be repaired through an

arthroscopic trans-tendon repair technique where
Surgical therapy for the impingement syn- a single row of suture anchors are placed at the
dromes is primarily directed at the rotator cuff, medial margin of the rotator cuff footprint [298,
which includes debridement or repair. Although 299] or surgical completion of the tear and subse-
many surgeons routinely perform partial quent full-thickness cuff repair [300]. A meta-
acromioplasty and coracoacromial ligament analysis published in 2015 found that the existing
release, existing level I and level II studies do evidence supports the trans-tendon technique
not support their routine use [293]. Incidence of rather than tear conversion followed by repair for
rotator cuff repairs is increasing, particularly partial-thickness articular sided tears involving
with arthroscopic techniques [294], which have more than 50% of the thickness [301]. Full-
become favored over open or mini-open tech- thickness tendon tears can be repaired in a num-
niques. In general, arthroscopic repair of full- ber of different ways, which depend on surgeon
thickness rotator cuff tears leads to good clinical preference and many patient variables. The goal
outcomes [295, 296]. Structural failure after of surgical treatment of full-thickness tendon
cuff repair is common, although counterintui- tears is to recreate the native anatomy. However,
tively a number of studies with high levels of full-thickness tears that have a large medial-lateral
evidence have shown a lack of correlation component with poor mobility of the retracted
between recurrent tear and clinical or functional tendon edge result in fewer choices for the ortho-
outcomes [295, 297]. This was confirmed in a pedic surgeon. Side-to-side suturing of the tendon
systemic review and meta-analysis published in edges can be performed to close the defect, either
2015 covering over 30 years of studies [296]. without (Fig. 5.12) [302] or with fixation of the
The reasons behind this are unclear and this converged tendon margin to bone [303].
remains an area of intense study. Torn rotator cuff tendons that can be reduced
to the greater tuberosity without undue tension
are transfixed with sutures that pass through bone
5.4.1 Techniques tunnels or through a suture anchor. These anchors
can be made of metal alloy or biocomposite
For appropriate interpretation of postoperative material, which may be partially or entirely bio-
images, familiarity with the common techniques resorbable [304]. Traditionally, arthroscopic
used for repair is necessary. High-grade partial- rotator cuff repair used a single row of suture
a b
c d
Fig. 5.12 54-year-old man with previous cuff repair revision surgery with scope in subacromial-subdeltoid
1 year prior, now with worsening shoulder pain and bursa through posterior portal shows side-to-side tendon
U-shaped tear. (a and b) Coronal oblique intermediate- repair. Sutures extend across U-shaped tear. (d) Coronal
weighted fat-suppressed MR images show a full-thickness oblique intermediate-weighted fat-suppressed MR image
retear of the supraspinatus tendon with differential retrac- 3 years after revision surgery shows an attenuated but
tion to the glenoid margin. Superior migration of the intact repair (dashed arrows). Subacromial-subdeltoid bur-
humeral head is evident. (c) Arthroscopic image during sitis was present, but no full-thickness tear was visualized
anchors placed in the greater tuberosity in a lin- pared with newer double-row techniques [306,
ear anterior-to-posterior configuration, which 307]. One double-row technique that has gained
could either be medial or lateral. However, this popularity is the transosseous equivalent, other-
has been shown to only restore approximately wise known as the suture bridge technique. This
67% of the original cuff footprint [305], and the was developed in 2006 by Park et al. [308] to
double-row repair was devised in an attempt to optimize footprint contact area, pressure, and
create more surface contact between the healing pullout strength. The transosseous equivalent
tendon and bone. The double-row repair was ini- technique uses a medial row of suture anchors
tially described with a medial row of anchors and a lateral row of knotless anchors. The double-
with sutures in a mattress configuration and a lat- row techniques, including the transosseous
eral row of anchors with sutures in a simple con- equivalent technique, are significantly stronger
figuration, but subsequent studies showed limited than single-row repairs in time-zero cadaveric
contact pressures between tendon and bone com- studies and several studies have suggested higher
rates of healing [295, 297, 309]. True arthroscopic arthrography. Prickett et al. used ultrasound to
transosseous (anchorless) fixation has also been evaluate postoperative rotator cuff integrity and
described [310], although biomechanical studies reported the sensitivity, specificity, and accuracy
have shown superior results with transosseous to be 91, 86, and 89%, respectively [312].
equivalent techniques [311]. However, Lee et al. found that accuracy of ultra-
sound for the postoperative cuff was 78% when
compared to MR arthrography [313]. They found
5.4.2 Imaging that ultrasound accuracy increased to 93% with
the use of intra-articular contrast (arthrosonogra-
In patients with persistent or new shoulder pain phy) [313]. MRI without or with intra-articular
after surgical therapy, imaging may be indicated. contrast can be used to evaluate the status of the
First-line imaging modalities of the postopera- repaired rotator cuff [300, 314–316] (Fig. 5.13).
tive cuff include ultrasound, MRI, or MR The appearance of the repaired rotator cuff on
a b
HH
c d
Fig. 5.13 52-year-old man with repair of full-thickness subacromial-subdeltoid bursa through posterior portal
supraspinatus tendon tear. (a) Coronal oblique after purple marking suture was placed through articular
intermediate-weighted MR image shows a focal full- side. Probe easily extended through bursal surface, con-
thickness tear of the supraspinatus tendon at the footprint firming the focal full-thickness tear (black arrowhead). (d)
(thick arrow) with delamination. (b) Arthroscopic image Coronal oblique T1-weighted fat-suppressed image
in glenohumeral joint through posterior portal confirms 2 years after repair shows well-healed footprint after
articular sided supraspinatus tendon tear (black arrows). single-row repair (dashed arrow)
Humeral head (HH) is marked. (c) Arthroscopic image in
a b
Fig. 5.14 65-Year-old woman status post-rotator cuff amount of tendon remains visible at the footprint (thin
repair 4 months prior with worsening shoulder pain and arrow). (b) Arthroscopic image during revision surgery
characteristic failure location after double-row repair. (a) with scope in subacromial-subdeltoid bursa through pos-
Coronal oblique intermediate-weighted fat-suppressed terior portal confirms full-thickness retear (thick arrows).
MR image shows a full-thickness retear of the distal Tear is centered medial to the medial row (arrowhead
supraspinatus tendon with retraction (thick arrow). Small marks medial row suture from initial repair)
MRI varies depending on the time of imaging. Similar to the transosseous equivalent technique,
Within the first 3 months, there can be increased the failure pattern in the double-row suture anchor
signal within the repaired cuff and the appear- method tends to involve the tendon near the medial
ance of poor footprint coverage, which can row rather than at the insertion [323] (Fig. 5.14).
improve by the first postoperative year [317]. In In 2015, Saccomanno et al. performed a sys-
a group of 15 asymptomatic patients 1.5–5 years tematic review of MRI criteria for the assessment
after rotator cuff repair, Spielmann et al. found of rotator cuff repair and identified 26 different
that only 10% of tendons demonstrated normal criteria that have been previously used [324].
low signal intensity [318]. This included structural integrity, footprint cov-
If there is unequivocal full-thickness fluid sig- erage, tendon thickness, signal intensity, partial
nal traversing the entire repaired tendon at any retearing, and muscle atrophy and fatty infiltra-
time point, a retear can be diagnosed [317, 319]. tion. The principal finding of the study was that,
Structural failure, as determined with imaging, is with the data available, only structural integrity
common after both single-row and double-row showed good intra- and inter-observer reliability
repair techniques. Multiple studies with high lev- [324]. Specifically, reliability was highest when a
els of evidence show conflicting results regarding binary classification scheme was used (dichoto-
retear rates after each technique, suggesting that mization of cuffs into intact versus retear groups).
there may not be a true difference between these
techniques [320, 321]. However, studies have sug-
gested characteristic tear patterns which are 5.5 Conclusion
dependent on technique. Cho et al. found that in a
single-row repair group, 74% of retearing occurred In summary, rotator cuff disease is common and
at the insertion site of the cuff, whereas in a tran- the diagnosis of impingement syndromes requires
sosseous equivalent group, 74% of retearing all available information, including history, phys-
occurred in the tendon near the medial row [322]. ical examination, and imaging. Our knowledge of
the anatomy involving the rotator cuff is rapidly 10. Milgrom C, Schaffler M, Gilbert S, van Holsbeeck
M. Rotator-cuff changes in asymptomatic adults.
evolving, and this has many clinical implications. The effect of age, hand dominance and gender. J
The etiology of rotator cuff disease is multifacto- Bone Joint Surg. 1995;77(2):296–8.
rial with intrinsic and extrinsic contributions and 11. Tempelhof S, Rupp S, Seil R. Age-related preva-
knowledge of both mechanisms is required for lence of rotator cuff tears in asymptomatic shoul-
ders. J Shoulder Elb Surg. 1999;8(4):296–9.
targeted therapy. Evaluation of the rotator cuff 12. Yuan J, Murrell GA, Wei AQ, Wang MX. Apoptosis
after surgery is challenging, but imaging plays an in rotator cuff tendonopathy. J Orthop Res.
important role and familiarity with the different 2002;20(6):1372–9. https://doi.org/10.1016/
repair techniques as well as expected and abnor- S0736-0266(02)00075-X.
13. Perry SM, McIlhenny SE, Hoffman MC, Soslowsky
mal postoperative appearances will aid the radi- LJ. Inflammatory and angiogenic mRNA levels are
ologist in making an accurate diagnosis. altered in a supraspinatus tendon overuse animal
model. J Shoulder Elb Surg. 2005;14(1 Suppl S):79S–
83S. https://doi.org/10.1016/j.jse.2004.09.020.
14. Jia XF, Ji JH, Pannirselvam V, Petersen SA,
References McFarland EG. Does a positive neer impingement
sign reflect rotator cuff contact with the acromion?
1. Teunis T, Lubberts B, Reilly BT, Ring D. A sys- Clin Orthop Relat Res. 2011;469(3):813–8. https://
tematic review and pooled analysis of the preva- doi.org/10.1007/s11999-010-1590-3.
lence of rotator cuff disease with increasing age. J 15. Hyvonen P, Paivansalo M, Lehtiniemi H, Leppilahti
Shoulder Elb Surg. 2014;23(12):1913–21. https:// J, Jalovaara P. Supraspinatus outlet view in the
doi.org/10.1016/j.jse.2014.08.001. diagnosis of stages II and III impingement syn-
2. Chakravarty K, Webley M. Shoulder joint move- drome. Acta Radiol. 2001;42(5):441–6. https://doi.
ment and its relationship to disability in the elderly. org/10.1080/028418501127347151.
J Rheumatol. 1993;20(8):1359–61. 16. Chang EY, Moses DA, Babb JS, Schweitzer
3. Chard MD, Hazleman BL. Shoulder disorders in ME. Shoulder impingement: objective 3D shape
the elderly (a hospital study). Ann Rheum Dis. analysis of acromial morphologic features.
1987;46(9):684–7. Radiology. 2006;239(2):497–505. https://doi.
4. Chard MD, Hazleman R, Hazleman BL, King RH, org/10.1148/radiol.2392050324.
Reiss BB. Shoulder disorders in the elderly: a com- 17. Moses DA, Chang EY, Schweitzer ME. The scapu-
munity survey. Arthritis Rheum. 1991;34(6):766–9. loacromial angle: a 3D analysis of acromial slope
5. van der Windt DA, Koes BW, de Jong BA, Bouter and its relationship with shoulder impingement. J
LM. Shoulder disorders in general practice: Magn Reson Imaging. 2006;24(6):1371–7. https://
incidence, patient characteristics, and management. doi.org/10.1002/jmri.20763.
Ann Rheum Dis. 1995;54(12):959–64. 18. Banas MP, Miller RJ, Totterman S. Relationship
6. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten between the lateral acromion angle and rotator cuff
KM, Bishop JY, Brophy RH, Carey JL, Holloway disease. J Shoulder Elb Surg. 1995;4(6):454–61.
GB, Jones GL, Ma CB, Marx RG, McCarty EC, 19. Harrison AK, Flatow EL. Subacromial impinge-
Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf ment syndrome. J Am Acad Orthop Surg.
BR, Wright RW. Symptoms of pain do not correlate 2011;19(11):701–8.
with rotator cuff tear severity: a cross-sectional study 20. Ricchetti ET, Aurora A, Iannotti JP, Derwin
of 393 patients with a symptomatic atraumatic full- KA. Scaffold devices for rotator cuff repair. J
thickness rotator cuff tear. J Bone Joint Surg Am. Shoulder Elb Surg. 2012;21(2):251–65. https://doi.
2014;96:793. https://doi.org/10.2106/jbjs.l.01304. org/10.1016/j.jse.2011.10.003.
7. Factor D, Dale B. Current concepts of rota- 21. Gulotta LV, Rodeo SA. Growth factors for rotator
tor cuff tendinopathy. Int J Sports Phys Ther. cuff repair. Clin Sports Med. 2009;28(1):13. https://
2014;9(2):274–88. doi.org/10.1016/j.csm.2008.09.002.
8. Lo IK, Burkhart SS. The etiology and assessment 22. Obaid H, Connell D. Cell therapy in tendon
of subscapularis tendon tears: a case for subcora- disorders what is the current evidence? Am J
coid impingement, the roller-wringer effect, and Sport Med. 2010;38(10):2123–32. https://doi.
TUFF lesions of the subscapularis. Arthroscopy. org/10.1177/0363546510373574.
2003;19(10):1142–50. https://doi.org/10.1016/j. 23. Riley GP, Harrall RL, Constant CR, Chard MD,
arthro.2003.10.024. Cawston TE, Hazleman BL. Tendon degenera-
9. Nho SJ, Yadav H, Shindle MK, Macgillivray tion and chronic shoulder pain: changes in the
JD. Rotator cuff degeneration: etiology and patho- collagen composition of the human rotator cuff
genesis. Am J Sports Med. 2008;36(5):987–93. tendons in rotator cuff tendinitis. Ann Rheum Dis.
https://doi.org/10.1177/0363546508317344. 1994;53(6):359–66.
24. Matuszewski PE, Chen YL, Szczesny SE, Lake SP, to medium-sized rotator cuff tears with and with-
Elliott DM, Soslowsky LJ, Dodge GR. Regional out disruption of the anterior supraspinatus tendon.
variation in human supraspinatus tendon proteo- J Shoulder Elb Surg. 2014;23(1):20–7. https://doi.
glycans: decorin, biglycan, and aggrecan. Connect org/10.1016/j.jse.2013.05.015.
Tissue Res. 2012;53(5):343–8. https://doi.org/10.31 37. Morag Y, Jamadar DA, Boon TA, Bedi A, Caoili
09/03008207.2012.654866. EM, Jacobson JA. Ultrasound of the rotator cable:
25. Clark JM, Harryman DT 2nd. Tendons, ligaments, prevalence and morphology in asymptomatic shoul-
and capsule of the rotator cuff. Gross and microscopic ders. AJR Am J Roentgenol. 2012;198(1):W27–30.
anatomy. J Bone Joint Surg Am. 1992;74(5):713–25. https://doi.org/10.2214/AJR.10.5796.
26. Chang EY, Chung CB. Current concepts on imag- 38. Gyftopoulos S, Bencardino J, Nevsky G, Hall G,
ing diagnosis of rotator cuff disease. Semin Soofi Y, Desai P, Jazrawi L, Recht MP. Rotator
Musculoskelet Radiol. 2014;18(4):412–24. https:// cable: MRI study of its appearance in the intact
doi.org/10.1055/s-0034-1384830. rotator cuff with anatomic and histologic correla-
27. Chang EY, Szeverenyi NM, Statum S, Chung tion. AJR Am J Roentgenol. 2013;200(5):1101–5.
CB. Rotator cuff tendon ultrastructure assessment https://doi.org/10.2214/AJR.12.9312.
with reduced-orientation dipolar anisotropy fiber 39. Morag Y, Jacobson JA, Lucas D, Miller B, Brigido
imaging. Am J Roentgenol. 2014;202(4):W376–8. MK, Jamadar DA. US appearance of the rota-
28. Burkhart SS, Esch JC, Jolson RS. The rotator cres- tor cable with histologic correlation: preliminary
cent and rotator cable: an anatomic description of results. Radiology. 2006;241(2):485–91. https://doi.
the shoulder's "suspension bridge". Arthroscopy. org/10.1148/radiol.2412050800.
1993;9(6):611–6. 40. Sheah K, Bredella MA, Warner JJP, Halpern EF,
29. Kolts I, Busch LC, Tomusk H, Arend A, Eller Palmer WE. Transverse thickening along the artic-
A, Merila M, Russlies M. Anatomy of the cora- ular surface of the rotator cuff consistent with the
cohumeral and coracoglenoidal ligaments. Ann rotator cable: identification with MR arthrography
Anat. 2000;182(6):563–6. https://doi.org/10.1016/ and relevance in rotator cuff evaluation. AJR Am J
S0940-9602(00)80105-3. Roentgenol. 2009;193(3):679–86.
30. Pouliart N, Somers K, Eid S, Gagey O. Variations 41. Nimura A, Akita K. Reply to: "The superior capsule
in the superior capsuloligamentous complex and of the shoulder joint complements the insertion of the
description of a new ligament. J Shoulder Elb rotator cuff". J Shoulder Elb Surg. 2013;22(2):e20–
Surg. 2007;16(6):821–36. https://doi.org/10.1016/j. 1. https://doi.org/10.1016/j.jse.2012.11.018.
jse.2007.02.138. 42. Nimura A, Kato A, Yamaguchi K, Mochizuki T,
31. Gohlke F, Essigkrug B, Schmitz F. The pattern of the Okawa A, Sugaya H, Akita K. The superior capsule
collagen fiber bundles of the capsule of the glenohu- of the shoulder joint complements the insertion of the
meral joint. J Shoulder Elb Surg. 1994;3(3):111–28. rotator cuff. J Shoulder Elb Surg. 2012;21(7):867–
https://doi.org/10.1016/S1058-2746(09)80090-6. 72. https://doi.org/10.1016/j.jse.2011.04.034.
32. Arai R, Nimura A, Yamaguchi K, Yoshimura H, 43. Cunningham DJ, Romanes GJ. Cunningham's
Sugaya H, Saji T, Matsuda S, Akita K. The anat- manual of practical anatomy. Oxford medical
omy of the coracohumeral ligament and its relation publications. 15th ed. New York: Oxford University
to the subscapularis muscle. J Shoulder Elb Surg. Press; 1986.
2014;23(10):1575–81. https://doi.org/10.1016/j. 44. Gray H, Standring S, Ellis H, Berkovitz BKB. Gray's
jse.2014.02.009. anatomy: the anatomical basis of clinical practice.
33. Nguyen ML, Quigley RJ, Galle SE, McGarry MH, 39th ed. New York: Elsevier Churchill Livingstone;
Jun BJ, Gupta R, Burkhart SS, Lee TQ. Margin con- 2005.
vergence anchorage to bone for reconstruction of the 45. Kim SY, Boynton EL, Ravichandiran K, Fung LY,
anterior attachment of the rotator cable. Arthroscopy. Bleakney R, Agur AM. Three-dimensional study
2012;28(9):1237–45. https://doi.org/10.1016/j. of the musculotendinous architecture of supraspi-
arthro.2012.02.016. natus and its functional correlations. Clin Anat.
34. Mesiha MM, Derwin KA, Sibole SC, Erdemir A, 2007;20(6):648–55. https://doi.org/10.1002/
McCarron JA. The biomechanical relevance of ante- ca.20469.
rior rotator cuff cable tears in a cadaveric shoulder 46. Roh MS, Wang VM, April EW, Pollock RG, Bigliani
model. J Bone Joint Surg. 2013;95(20):1817–24. LU, Flatow EL. Anterior and posterior musculoten-
https://doi.org/10.2106/JBJS.L.00784. dinous anatomy of the supraspinatus. J Shoulder Elb
35. Araki D, Miller RM, Fujimaki Y, Hoshino Y, Musahl Surg. 2000;9(5):436–40. https://doi.org/10.1067/
V, Debski RE. Effect of tear location on propaga- mse.2000.108387.
tion of isolated supraspinatus tendon tears during 47. Huang CY, Wang VM, Pawluk RJ, Bucchieri
increasing levels of cyclic loading. J Bone Joint JS, Levine WN, Bigliani LU, Mow VC, Flatow
Surg. 2015;97(4):273–8. https://doi.org/10.2106/ EL. Inhomogeneous mechanical behavior of the
JBJS.N.00062. human supraspinatus tendon under uniaxial load-
36. Namdari S, Donegan RP, Dahiya N, Galatz LM, ing. J Orthop Res. 2005;23(4):924–30. https://doi.
Yamaguchi K, Keener JD. Characteristics of small org/10.1016/j.orthres.2004.02.016.
48. Curtis AS, Burbank KM, Tierney JJ, Scheller AD, 61. Ruotolo C, Fow JE, Nottage WM. The supraspina-
Curran AR. The insertional footprint of the rotator tus footprint: an anatomic study of the supraspinatus
cuff: an anatomic study. Arthroscopy. 2006;22(6):609 insertion. Arthroscopy. 2004;20(3):246–9. https://
e601. https://doi.org/10.1016/j.arthro.2006.04.001. doi.org/10.1016/j.arthro.2004.01.002.
49. Minagawa H, Itoi E, Konno N, Kido T, Sano A, 62. Karthikeyan S, Rai SB, Parsons H, Drew S, Smith
Urayama M, Sato K. Humeral attachment of the CD, Griffin DR. Ultrasound dimensions of the rota-
supraspinatus and infraspinatus tendons: an ana- tor cuff in young healthy adults. J Shoulder Elb Surg.
tomic study. Arthroscopy. 1998;14(3):302–6. 2014;23(8):1107–12. https://doi.org/10.1016/j.
50. Lumsdaine W, Smith A, Walker RG, Benz D, jse.2013.11.012.
Mohammed KD, Stewart F. Morphology of the 63. Kato A, Nimura A, Yamaguchi K, Mochizuki T,
humeral insertion of the supraspinatus and infraspi- Sugaya H, Akita K. An anatomical study of the trans-
natus tendons: application to rotator cuff repair. Clin verse part of the infraspinatus muscle that is closely
Anat. 2015;28(6):767–73. https://doi.org/10.1002/ related with the supraspinatus muscle. Surg Radiol
ca.22548. Anat. 2012;34(3):257–65. https://doi.org/10.1007/
51. Mochizuki T, Sugaya H, Uomizu M, Maeda K, s00276-011-0872-0.
Matsuki K, Sekiya I, Muneta T, Akita K. Humeral 64. Seo JB, Yoo JS, Jang HS, Kim JS. Correlation of
insertion of the supraspinatus and infraspinatus. New clinical symptoms and function with fatty degenera-
anatomical findings regarding the footprint of the tion of infraspinatus in rotator cuff tear. Knee Surg
rotator cuff. J Bone Joint Surg Am. 2008;90(5):962– Sports Traumatol Arthrosc. 2015;23(5):1481–8.
9. https://doi.org/10.2106/JBJS.G.00427. https://doi.org/10.1007/s00167-014-2857-0.
52. Moser TP, Cardinal E, Bureau NJ, Guillin R, 65. Le Corroller T, Aswad R, Pauly V, Champsaur
Lanneville P, Grabs D. The aponeurotic expan- P. Orientation of the rotator cuff insertion facets
sion of the supraspinatus tendon: anatomy and on the humerus: comparison between individu-
prevalence in a series of 150 shoulder MRIs. Skelet als with intact and torn rotator cuffs. Ann Anat.
Radiol. 2015;44(2):223–31. https://doi.org/10.1007/ 2009;191(2):218–24. https://doi.org/10.1016/j.
s00256-014-1993-4. aanat.2008.10.003.
53. Brodie CG. Note on the transverse-humeral, coraco- 66. Yoo JC, Rhee YG, Shin SJ, Park YB, McGarry MH,
acromial, and coraco-humeral ligaments, &c. J Anat Jun BJ, Lee TQ. Subscapularis tendon tear classifi-
Physiol. 1890;24(Pt 2):247–52. cation based on 3-dimensional anatomic footprint:
54. Hammad RB, Mohamed A. Unilateral four- a cadaveric and prospective clinical observational
headed pectoralis muscle major. Mcgill J Med. study. Arthroscopy. 2015;31(1):19–28. https://doi.
2006;9(1):28–30. org/10.1016/j.arthro.2014.08.015.
55. Gheno R, Zoner CS, Buck FM, Nico MA, Haghighi 67. Michelin P, Trintignac A, Dacher JN, Carvalhana G,
P, Trudell DJ, Resnick D. Accessory head of biceps Lefebvre V, Duparc F. Magnetic resonance anatomy
brachii muscle: anatomy, histology, and MRI in of the superior part of the rotator cuff in normal
cadavers. AJR Am J Roentgenol. 2010;194(1):W80– shoulders, assessment and practical implication.
3. https://doi.org/10.2214/AJR.09.3158. Surg Radiol Anat. 2014;36(10):993–1000. https://
56. Lutterbach-Penna RA, Brigido MK, Robertson B, doi.org/10.1007/s00276-014-1331-5.
Kim SM, Jacobson JA, Fessell DP. Sonography of 68. Michelin P, Kasprzak K, Dacher J, Lefebvre V,
the accessory head of the biceps brachii. J Ultrasound Duparc F. Ultrasound and anatomical assessment
Med. 2014;33(10):1851–4. https://doi.org/10.7863/ of the infraspinatus tendon through anterosuperolat-
ultra.33.10.1851. eral approach. Eur Radiol. 2015;25:1–6. https://doi.
57. Moser TP, Bureau NJ, Grabs D, Cardinal E. org/10.1007/s00330-015-3614-6.
Accessory head of the biceps tendon versus apo- 69. Resnick D, Kang HS, Pretterklieber ML. Internal
neurotic expansion of the supraspinatus tendon. J derangements of joints. 2nd ed. Philadelphia:
Ultrasound Med. 2015;34(1):173–4. https://doi.org/ Saunders/Elsevier; 2007.
10.7863/ultra.34.1.173. 70. Nimura A, Akita K, Sugaya H. Rotator cuff. In:
58. Ellman H. Diagnosis and treatment of incom- Bain GI, Itoi E, Di Giacomo G, Sugaya H, editors.
plete rotator cuff tears. Clin Orthop Relat Res. Normal and pathological anatomy of the shoulder.
1990;254:64–74. Berlin Heidelberg: Springer; 2015. p. 199–205.
59. Nozaki T, Nimura A, Fujishiro H, Mochizuki T, https://doi.org/10.1007/978-3-662-45719-1_20.
Yamaguchi K, Kato R, Sugaya H, Akita K. The 71. Saji T, Arai R, Harada H, Tsukiyama H, Miura T,
anatomic relationship between the morphology of Matsuda S Anatomical study on the origin and the
the greater tubercle of the humerus and the inser- insertion of the teres minor muscle. In: ISAKOS,
tion of the infraspinatus tendon. J Shoulder Elb Toronto, Canada; 2013. p. 2013.
Surg. 2015;24(4):555–60. https://doi.org/10.1016/j. 72. Gray H, Clemente CD. Anatomy of the human body.
jse.2014.09.038. 30th ed. Philadelphia: Lea & Febiger; 1985.
60. Dugas JR, Campbell DA, Warren RF, Robie BH, 73. Arai R, Sugaya H, Mochizuki T, Nimura A,
Millett PJ. Anatomy and dimensions of rotator cuff Moriishi J, Akita K. Subscapularis tendon tear: an
insertions. J Shoulder Elb Surg. 2002;11(5):498–503. anatomic and clinical investigation. Arthroscopy.
2008;24(9):997–1004. https://doi.org/10.1016/j. 88. Fukuda H, Hamada K, Nakajima T, Tomonaga

arthro.2008.04.076. A. Pathology and pathogenesis of the intratendi-
74. Richards DP, Burkhart SS, Tehrany AM, Wirth nous tearing of the rotator cuff viewed from en
MA. The subscapularis footprint: an anatomic bloc histologic sections. Clin Orthop Relat Res.
description of its insertion site. Arthroscopy. 1994;304:60–7.
2007;23(3):251–4. https://doi.org/10.1016/j.arthro. 89. Codman EA, Akerson IB. The pathology associated
2006.11.023. with rupture of the supraspinatus tendon. Ann Surg.
75. DePalma AF. Surgery of the shoulder. 3rd ed. 1931;93(1):348–59.
Philadelphia: Lippincott; 1983. 90. Mazzocca AD, Rincon LM, O'Connor RW,
76. Di Giacomo G (2008) Atlas of functional shoulder Obopilwe E, Andersen M, Geaney L, Arciero
anatomy. RA. Intra-articular partial-thickness rotator cuff
77. Pouliart N, Boulet C, Maeseneer MD, Shahabpour tears: analysis of injured and repaired strain behav-
M. Advanced imaging of the glenohumeral ligaments. ior. Am J Sports Med. 2008;36(1):110–6. https://doi.
Semin Musculoskelet Radiol. 2014;18(4):374–97. org/10.1177/0363546507307502.
https://doi.org/10.1055/s-0034-1384827. 91. Strauss EJ, Salata MJ, Kercher J, Barker JU, McGill
78. Arai R, Mochizuki T, Yamaguchi K, Sugaya H, K, Bach BR Jr, Romeo AA, Verma NN. Multimedia
Kobayashi M, Nakamura T, Akita K. Functional article. The arthroscopic management of partial-
anatomy of the superior glenohumeral and coraco- thickness rotator cuff tears: a systematic review of
humeral ligaments and the subscapularis tendon in the literature. Arthroscopy. 2011;27(4):568–80.
view of stabilization of the long head of the biceps 92. Shindle MK, Chen CCT, Robertson C, DiTullio AE,
tendon. J Shoulder Elb Surg. 2010;19(1):58–64. Paulus MC, Clinton CM, Cordasco FA, Rodeo SA,
https://doi.org/10.1016/j.jse.2009.04.001. Warren RF. Full-thickness supraspinatus tears are
79. D'Addesi LL, Anbari A, Reish MW, Brahmabhatt associated with more synovial inflammation and
S, Kelly JD. The subscapularis footprint: an ana- tissue degeneration than partial-thickness tears. J
tomic study of the subscapularis tendon inser- Shoulder Elb Surg. 2011;20(6):917–27. https://doi.
tion. Arthroscopy. 2006;22(9):937–40. https://doi. org/10.1016/j.jse.2011.02.015.
org/10.1016/j.arthro.2006.04.101. 93. Lo IK, Burkhart SS. Current concepts in
80. Werner A, Mueller T, Boehm D, Gohlke F. The stabi- arthroscopic rotator cuff repair. Am J Sports Med.
lizing sling for the long head of the biceps tendon in 2003;31(2):308–24.
the rotator cuff interval. A histoanatomic study. Am 94. Sela Y, Eshed I, Shapira S, Oran A, Vogel G,
J Sports Med. 2000;28(1):28–31. Herman A, Perry M. Rotator cuff tears: correla-
81. Chard MD, Cawston TE, Riley GP, Gresham GA, tion between geometric tear patterns on MRI and
Hazleman BL. Rotator cuff degeneration and lateral arthroscopy and pre- and postoperative clinical
epicondylitis: a comparative histological study. Ann findings. Acta Radiol. 2015;56(2):182–9. https://doi.
Rheum Dis. 1994;53(1):30–4. org/10.1177/0284185114520861.
82. Jarvinen M, Jozsa L, Kannus P, Jarvinen TL, Kvist 95. Lee YH, Kim AH, Suh JS. Magnetic resonance
M, Leadbetter W. Histopathological findings in visualization of surgical classification of rotator
chronic tendon disorders. Scand J Med Sci Sports. cuff tear: comparison with three-dimensional shoul-
1997;7(2):86–95. der magnetic resonance arthrography at 3.0 T. Clin
83. Berenson MC, Blevins FT, Plaas AH, Vogel Imag. 2014;38(6):858–63. https://doi.org/10.1016/j.
KG. Proteoglycans of human rotator cuff tendons. clinimag.2014.07.003.
J Orthop Res. 1996;14(4):518–25. https://doi. 96. Tauro JC. Arthroscopic repair of large rotator cuff
org/10.1002/jor.1100140404. tears using the interval slide technique. Arthroscopy.
84. Weber SC. Arthroscopic debridement and acromio- 2004;20(1):13–21.
plasty versus mini-open repair in the treatment 97. Cofield RH. Subscapular muscle transposition for
of significant partial-thickness rotator cuff tears. repair of chronic rotator cuff tears. Surg Gynecol
Arthroscopy. 1999;15(2):126–31. https://doi. Obstet. 1982;154(5):667–72.
org/10.1053/ar.1999.v15.0150121. 98. Pill SG, Phillips J, Kissenberth MJ, Hawkins
85. Fukuda H. The management of partial- thickness RJ. Decision making in massive rotator cuff tears.
tears of the rotator cuff. J Bone Joint Surg. Instr Course Lect. 2012;61:97–111.
2003;85(1):3–11. 99. Delaney RA, Lin A, Warner JJ. Nonarthroplasty
86. Kim HM, Dahiya N, Teefey SA, Middleton WD, options for the management of massive and
Stobbs G, Steger-May K, Yamaguchi K, Keener irreparable rotator cuff tears. Clin Sports Med.
JD. Location and initiation of degenerative rotator 2012;31(4):727–48. https://doi.org/10.1016/j.
cuff tears: an analysis of three hundred and sixty csm.2012.07.008.
shoulders. J Bone Joint Surg Am. 2010;92(5):1088– 100. Choo HJ, Lee SJ, Kim JH, Kim DW, Park YM,
96. https://doi.org/10.2106/JBJS.I.00686. Kim OH, Kim SJ. Delaminated tears of the rota-
87. Fukuda H, Hamada K, Yamanaka K. Pathology and tor cuff: prevalence, characteristics, and diagnos-
pathogenesis of bursal-side rotator cuff tears viewed tic accuracy using indirect MR arthrography. AJR
from en bloc histologic sections. Clin Orthop Relat Am J Roentgenol. 2015;204(2):360–6. https://doi.
Res. 1990;254:75–80. org/10.2214/AJR.14.12555.
101. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is pos- 113. Tasaki A, Nimura A, Nozaki T, Yamakawa A, Niitsu
terior delamination in arthroscopic rotator cuff repair M, Morita W, Hoshikawa Y, Akita K. Quantitative
hidden to the posterior viewing portal? Arthroscopy. and qualitative analyses of subacromial impinge-
2013;29(11):1740–7. https://doi.org/10.1016/j. ment by kinematic open MRI. Knee Surg Sport Tr
arthro.2013.08.021. A. 2015;23(5):1489–97. https://doi.org/10.1007/
102. Meyer DC, Hoppeler H, von Rechenberg B, Gerber s00167-014-2876-x.
C. A pathomechanical concept explains muscle loss 114. Alfredson H, Forsgren S, Thorsen K, Lorentzon
and fatty muscular changes following surgical ten- R. In vivo microdialysis and immunohistochemi-
don release. J Orthop Res. 2004;22(5):1004–7. cal analyses of tendon tissue demonstrated high
103. Albritton MJ, Graham RD, Richards RS 2nd, amounts of free glutamate and glutamate NMDAR1
Basamania CJ. An anatomic study of the effects receptors, but no signs of inflammation, in Jumper's
on the suprascapular nerve due to retraction of the knee. J Orthopaed Res. 2001;19(5):881–6. https://
supraspinatus muscle after a rotator cuff tear. J doi.org/10.1016/S0736-0266(01)00016-X.
Shoulder Elb Surg. 2003;12(5):497–500. 115. Alfredson H, Lorentzon R. Chronic tendon pain: no
104. Gladstone JN, Bishop JY, Lo IK, Flatow signs of chemical inflammation but high concentra-
EL. Fatty infiltration and atrophy of the rota- tions of the neurotransmitter glutamate. Implications
tor cuff do not improve after rotator cuff repair for treatment? Curr Drug Targets. 2002;3(1):43–54.
and correlate with poor functional outcome. Am https://doi.org/10.2174/1389450023348028.
J Sports Med. 2007;35(5):719–28. https://doi. 116. Gellhorn AC, Gillenwater C, Mourad PD. Intense
org/10.1177/0363546506297539. focused ultrasound stimulation of the rotator cuff:
105. Kuzel BR, Grindel S, Papandrea R, Ziegler D. Fatty evaluation of the source of pain in rotator cuff
infiltration and rotator cuff atrophy. J Am Acad tears and tendinopathy. Ultrasound Med Biol.
Orthop Surg. 2013;21(10):613–23. https://doi. 2015;41(9):2412–9. https://doi.org/10.1016/j.
org/10.5435/JAAOS-21-10-613. ultrasmedbio.2015.05.005.
106. Chaudhury S, Dines JS, Delos D, Warren RF, Voigt 117. Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K,
C, Rodeo SA. Role of fatty infiltration in the patho- Tamai S. Tears of the rotator cuff of the shoulder
physiology and outcomes of rotator cuff tears. associated with pathological changes in the acro-
Arthritis Care Res. 2012;64(1):76–82. https://doi. mion. A study in cadavera. Muscles Ligaments
org/10.1002/acr.20552. Tendons J. 1988;70(8):1224–30.
107. Sarkar K, Taine W, Uhthoff HK. The ultrastructure 118. Getz JD, Recht MP, Piraino DW, Schils JP, Latimer
of the coracoacromial ligament in patients with BM, Jellema LM, Obuchowski NA. Acromial
chronic impingement syndrome. Clin Orthop Relat morphology: relation to sex, age, symmetry,
Res. 1990;254:49–54. and subacromial enthesophytes. Radiology.
108. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber 1996;199(3):737–42. https://doi.org/10.1148/
R, de Ruiter T, Willems J, Winters J, van der Woude radiology.199.3.8637998.
HJ, Dutch Orthopaedic A. Guideline for diagno- 119. Fujisawa Y, Mihata T, Murase T, Sugamoto K,
sis and treatment of subacromial pain syndrome: a Neo M. Three-dimensional analysis of acro-
multidisciplinary review by the Dutch Orthopaedic mial morphologic characteristics in patients with
Association. Acta Orthop. 2014;85(3):314–22. and without rotator cuff tears using a recon-
https://doi.org/10.3109/17453674.2014.920991. structed computed tomography model. Am J
109. McFarland EG, Maffulli N, Del Buono A, Murrell Sport Med. 2014;42(11):2621–6. https://doi.
GA, Garzon-Muvdi J, Petersen SA. Impingement org/10.1177/0363546514544683.
is not impingement: the case for calling it “Rotator 120. Bigliani LU, Morrison DS, April EW. The morphol-
Cuff Disease”. Muscles Ligaments Tendons J. ogy of the acromion and its relationship to rotator
2013;3(3):196–200. cuff tears. Orthop Trans. 1986;10:216.
110. Papadonikolakis A, McKenna M, Warme W, Martin 121. Zuckerman JD, Kummer FJ, Cuomo F, Greller
BI, Matsen FA 3rd. Published evidence relevant M. Interobserver reliability of acromial morphol-
to the diagnosis of impingement syndrome of the ogy classification: an anatomic study. J Shoulder Elb
shoulder. J Bone Joint Surg Am. 2011;93(19):1827– Surg. 1997;6(3):286–7.
32. https://doi.org/10.2106/JBJS.J.01748. 122. Peh WC, Farmer TH, Totty WG. Acromial arch
111. Neer CS 2nd. Anterior acromioplasty for the shape: assessment with MR imaging. Radiology.
chronic impingement syndrome in the shoulder: a 1995;195(2):501–5. https://doi.org/10.1148/
preliminary report. Muscles Ligaments Tendons J. radiology.195.2.7724774.
1972;54(1):41–50. 123. Epstein RE, Schweitzer ME, Frieman BG, Fenlin
112. Yamamoto N, Muraki T, Sperling JW, Steinmann JM Jr, Mitchell DG. Hooked acromion: prevalence
SP, Itoi E, Cofield RH, An KN. Contact between on MR images of painful shoulders. Radiology.
the coracoacromial arch and the rotator cuff ten- 1993;187(2):479–81. https://doi.org/10.1148/
dons in nonpathologic situations: a cadaveric study. radiology.187.2.8475294.
J Shoulder Elb Surg. 2010;19(5):681–7. https://doi. 124. Mayerhoefer ME, Breitenseher MJ, Roposch A,
org/10.1016/j.jse.2009.12.006. Treitl C, Wurnig C. Comparison of MRI and conven-
tional radiography for assessment of acromial shape. changes and rotator cuff tears. Arthroscopy.
AJR Am J Roentgenol. 2005;184(2):671–5. https:// 1996;12(5):531–40. https://doi.org/10.1016/
doi.org/10.2214/ajr.184.2.01840671. S0749-8063(96)90190-5.
125. Haygood TM, Langlotz CP, Kneeland JB, Iannotti 138. Zuckerman JD, Kummer FJ, Cuomo F, Simon J,
JP, Williams GR Jr, Dalinka MK. Categorization of Rosenblum S, Katz N. The influence of coracoacro-
acromial shape: interobserver variability with MR mial arch anatomy on rotator cuff tears. J Shoulder
imaging and conventional radiography. AJR Am Elb Surg. 1992;1(1):4–14. https://doi.org/10.1016/
J Roentgenol. 1994;162(6):1377–82. https://doi. S1058-2746(09)80010-4.
org/10.2214/ajr.162.6.8192003. 139. Balke M, Liem D, Greshake O, Hoeher J, Bouillon
126. Bright AS, Torpey B, Magid D, Codd T, B, Banerjee M. Differences in acromial morphology
McFarland EG. Reliability of radiographic evalu- of shoulders in patients with degenerative and trau-
ation for acromial morphology. Skelet Radiol. matic supraspinatus tendon tears. Knee Surg Sports
1997;26(12):718–21. Traumatol Arthrosc. 2014;24(7):2200–5. https://doi.
127. Jacobson SR, Speer KP, Moor JT, Janda DH, org/10.1007/s00167-014-3499-y.
Saddemi SR, MacDonald PB, Mallon WJ. Reliability 140. MacGillivray JD, Fealy S, Potter HG, O'Brien
of radiographic assessment of acromial morphology. SJ. Multiplanar analysis of acromion morphology.
J Shoulder Elb Surg. 1995;4(6):449–53. Am J Sports Med. 1998;26(6):836–40.
128. Chambler AF, Emery RJ. Acromial morphol- 141. Kibler WB. Scapular involvement in impinge-
ogy: the enigma of terminology. Knee Surg Sports ment: signs and symptoms. Instr Course Lect.
Traumatol Arthrosc. 1997;5(4):268–72. https://doi. 2006;55:35–43.
org/10.1007/s001670050062. 142. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there
129. Nicholson GP, Goodman DA, Flatow EL, Bigliani a relationship between subacromial impingement
LU. The acromion: morphologic condition and age- syndrome and scapular orientation? A systematic
related changes. A study of 420 scapulas. J Shoulder review. Brit J Sport Med. 2014;48(16):1251–U1282.
Elb Surg. 1996;5:1):1–11. https://doi.org/10.1136/bjsports-2013-092389.
130. Shah NN, Bayliss NC, Malcolm A. Shape of the 143. Petersson CJ, Gentz CF. Ruptures of the supraspi-
acromion: congenital or acquired--a macroscopic, natus tendon. The significance of distally pointing
radiographic, and microscopic study of acromion. J acromioclavicular osteophytes. Clin Orthop Relat
Shoulder Elb Surg. 2001;10(4):309–16. https://doi. Res. 1983;174:143–8.
org/10.1067/mse.2001.114681. 144. Cuomo F, Kummer FJ, Zuckerman JD, Lyon T, Blair
131. Speer KP, Osbahr DC, Montella BJ, Apple AS, B, Olsen T. The influence of acromioclavicular joint
Mair SD. Acromial morphotype in the young morphology on rotator cuff tears. J Shoulder Elb
asymptomatic athletic shoulder. J Shoulder Elb Surg. 1998;7(6):555–9.
Surg. 2001;10(5):434–7. https://doi.org/10.1067/ 145. de Abreu MR, Chung CB, Wesselly M, Jin-Kim H,
mse.2001.117124. Resnick D. Acromioclavicular joint osteoarthritis:
132. Toivonen DA, Tuite MJ, Orwin JF. Acromial struc- comparison of findings derived from MR imag-
ture and tears of the rotator cuff. J Shoulder Elb ing and conventional radiography. Clin Imaging.
Surg. 1995;4(5):376–83. 2005;29(4):273–7. https://doi.org/10.1016/j.
133. Tuite MJ, Toivonen DA, Orwin JF, Wright clinimag.2004.11.021.
DH. Acromial angle on radiographs of the shoul- 146. Blasiak A, Mojzesz M, Brzoska R, Solecki W,
der: correlation with the impingement syndrome Binkowska A. Results of arthroscopic treatment of
and rotator cuff tears. AJR Am J Roentgenol. rotator cuff tear with the resection of symptomatic
1995;165(3):609–13. https://doi.org/10.2214/ acromioclavicular joint with degenerative changes.
ajr.165.3.7645479. Pol Orthop Traumatol. 2013;78:229–34.
134. Farley TE, Neumann CH, Steinbach LS, Petersen 147. Daluga DJ, Dobozi W. The influence of distal clavi-
SA. The coracoacromial arch: MR evaluation and cle resection and rotator cuff repair on the effective-
correlation with rotator cuff pathology. Skelet ness of anterior acromioplasty. Clin Orthop Relat
Radiol. 1994;23(8):641–5. Res. 1989;247:117–23.
135. Wang JC, Horner G, Brown ED, Shapiro MS. The 148. Kay SP, Dragoo JL, Lee R. Long-term results of
relationship between acromial morphology and con- arthroscopic resection of the distal clavicle with con-
servative treatment of patients with impingement comitant subacromial decompression. Arthroscopy.
syndrome. Orthopedics. 2000;23(6):557–9. 2003;19(8):805–9.
136. Tasu JP, Miquel A, Rocher L, Molina V, Gagey O, 149. Kim J, Chung J, Ok H. Asymptomatic acromiocla-
Blery M. MR evaluation of factors predicting the vicular joint arthritis in arthroscopic rotator cuff
development of rotator cuff tears. J Comput Assist tendon repair: a prospective randomized comparison
Tomogr. 2001;25(2):159–63. study. Arch Orthop Trauma Surg. 2011;131(3):363–
137. Panni AS, Milano G, Lucania L, Fabbriciani C, 9. https://doi.org/10.1007/s00402-010-1216-y.
Logroscino CA. Histological analysis of the cora- 150. Levine WN, Soong M, Ahmad CS, Blaine TA,
coacromial arch: Correlation between age-related Bigliani LU. Arthroscopic distal clavicle resec-
tion: a comparison of bursal and direct approaches. domized controlled trial. J Bone Joint Surg Am.
Arthroscopy. 2006;22(5):516–20. https://doi. 2011;93(21):1953–60. https://doi.org/10.2106/
org/10.1016/j.arthro.2006.01.013. JBJS.K.00488.
151. Lozman PR, Hechtman KS, Uribe JW. Combined 162. Milano G, Grasso A, Salvatore M, Zarelli D,
arthroscopic management of impingement syn- Deriu L, Fabbriciani C. Arthroscopic rotator cuff
drome and acromioclavicular joint arthritis. J South repair with and without subacromial decompres-
Orthop Assoc. 1995;4(3):177–81. sion: a prospective randomized study. Arthroscopy.
152. Snyder SJ, Banas MP, Karzel RP. The arthroscopic 2007;23(1):81–8. https://doi.org/10.1016/j.
Mumford procedure: an analysis of results. arthro.2006.10.011.
Arthroscopy. 1995;11(2):157–64. 163. Moorman CT, Warren RF, Deng XH, Wickiewicz
153. Razmjou H, ElMaraghy A, Dwyer T, Fournier- TL, Torzilli PA. Role of coracoacromial ligament and
Gosselin S, Devereaux M, Holtby R. Outcome of related structures in glenohumeral stability: a cadav-
distal clavicle resection in patients with acromio- eric study. J Surg Orthop Adv. 2012;21(4):210–7.
clavicular joint osteoarthritis and full-thickness 164. Edelson JG, Zuckerman J, Hershkovitz I. Os acro-
rotator cuff tear. Knee surgery, sports traumatol- miale: anatomy and surgical implications. J Bone
ogy. Arthroscopy. 2015;23(2):585–90. https://doi. Joint Surg. 1993;75(4):551–5.
org/10.1007/s00167-014-3114-2. 165. Mudge MK, Wood VE, Frykman GK. Rotator
154. Oh JH, Kim JY, Choi JH, Park S-M. Is cuff tears associated with os acromiale. Muscles
arthroscopic distal clavicle resection necessary Ligaments Tendons J. 1984;66(3):427–9.
for patients with radiological acromioclavicu- 166. Yammine K. The prevalence of os acromiale: A
lar joint arthritis and rotator cuff tears? A pro- systematic review and meta-analysis. Clin Anat.
spective randomized comparative study. Am J 2014;27(4):610–21. https://doi.org/10.1002/ca.22343.
Sports Med. 2014;42(11):2567–73. https://doi. 167. Sammarco VJ. Os acromiale: frequency, anatomy,
org/10.1177/0363546514547254. and clinical implications. J Bone Joint Surg Am.
155. Park YB, Koh KH, Shon MS, Park YE, Yoo 2000;82(3):394–400.
JC. Arthroscopic distal clavicle resection in symp- 168. Kurtz CA, Humble BJ, Rodosky MW, Sekiya
tomatic acromioclavicular joint arthritis combined JK. Symptomatic os acromiale. J Am Acad Orthop
with rotator cuff tear: a prospective randomized trial. Surg. 2006;14(1):12–9.
Am J Sports Med. 2015;43(4):985–90. https://doi. 169. Wise JN, Daffner RH, Weissman BN, Bancroft
org/10.1177/0363546514563911. L, Bennett DL, Blebea JS, Bruno MA, Fries IB,
156. Kesmezacar H, Akgun I, Ogut T, Gokay S, Uzun Jacobson JA, Luchs JS, Morrison WB, Resnik
I. The coracoacromial ligament: the morphology CS, Roberts CC, Schweitzer ME, Seeger LL,
and relation to rotator cuff pathology. J Shoulder Elb Stoller DW, Taljanovic MS. ACR Appropriateness
Surg. 2008;17(1):182–8. https://doi.org/10.1016/j. Criteria(R) on acute shoulder pain. J Am Coll
jse.2007.05.015. Radiol. 2011;8(9):602–9. https://doi.org/10.1016/j.
157. Holt EM, Allibone RO. Anatomic variants of the jacr.2011.05.008.
coracoacromial ligament. J Shoulder Elb Surg. 170. McCreesh KM, Crotty JM, Lewis
1995;4(5):370–5. JS. Acromiohumeral distance measurement in rota-
158. Fealy S, April EW, Khazzam M, Armengol-Barallat tor cuff tendinopathy: is there a reliable, clinically
J, Bigliani LU. The coracoacromial ligament: mor- applicable method? A systematic review. Brit J Sport
phology and study of acromial enthesopathy. J Med. 2015;49(5):298–305. https://doi.org/10.1136/
Shoulder Elb Surg. 2005;14(5):542–8. https://doi. bjsports-2012-092063.
org/10.1016/j.jse.2005.02.006. 171. Petersson CJ, Redlund-Johnell I. The subacromial
159. Abrams GD, Gupta AK, Hussey KE, Tetteh ES, space in normal shoulder radiographs. Acta Orthop
Karas V, Bach BR Jr, Cole BJ, Romeo AA, Verma Scand. 1984;55(1):57–8.
NN. Arthroscopic repair of full-thickness rotator 172. Saupe N, Pfirrmann CWA, Schmid MR, Jost B,
cuff tears with and without acromioplasty: random- Werner CML, Zanetti M. Association between rota-
ized prospective trial with 2-year follow-up. Am tor cuff abnormalities and reduced acromiohumeral
J Sports Med. 2014;42(6):1296–303. https://doi. distance. Am J Roentgenol. 2006;187(2):376–82.
org/10.1177/0363546514529091. https://doi.org/10.2214/Ajr.05.0435.
160. Gartsman GM, O'Connor DP. Arthroscopic rota- 173. Nove-Josserand L, Levigne C, Noel E, Walch G. The
tor cuff repair with and without arthroscopic acromio-humeral interval. A study of the factors
subacromial decompression: a prospective, random- influencing its height. Rev Chir Orthop Reparatrice
ized study of one-year outcomes. J Shoulder Elb Appar Mot. 1996;82(5):379–85.
Surg. 2004;13(4):424–6. https://doi.org/10.1016/ 174. Goutallier D, Le Guilloux P, Postel JM, Radier
S1058274604000527. C, Bernageau J, Zilber S. Acromio humeral dis-
161. MacDonald P, McRae S, Leiter J, Mascarenhas tance less than six millimeter: Its meaning in full-
R, Lapner P. Arthroscopic rotator cuff repair with thickness rotator cuff tear. Orthop Traumatol Sur.
and without acromioplasty in the treatment of 2011;97(3):246–51. https://doi.org/10.1016/j.
full-thickness rotator cuff tears: a multicenter, ran- otsr.2011.01.010.
175. Huang LF, Rubin DA, Britton CA. Greater tuberos- J Shoulder Elb Surg. 2013;22(7):901–7. https://doi.
ity changes as revealed by radiography: lack of clini- org/10.1016/j.jse.2012.09.015.
cal usefulness in patients with rotator cuff disease. 187. Pearsall AW, Bonsell S, Heitman RJ, Helms CA,
Am J Roentgenol. 1999;172(5):1381–8. Osbahr D, Speer KP. Radiographic findings asso-
176. Fritz LB, Ouellette HA, O'Hanley TA, Kassarjian ciated with symptomatic rotator cuff tears. J
A, Palmer WE. Cystic changes at supraspinatus and Shoulder Elb Surg. 2003;12(2):122–7. https://doi.
infraspinatus tendon insertion sites: Association org/10.1067/mse.2003.19.
with age and rotator cuff disorders in 238 patients. 188. Berens DL, Lockie LM. Ossification of the coraco-
Radiology. 2007;244(1):239–48. https://doi. acromial ligament. Radiology. 1960;74:802–5.
org/10.1148/radiol.2441050029. https://doi.org/10.1148/74.5.802.
177. Sano A, Itoi E, Konno N, Kido T, Urayama M, 189. Cone RO 3rd, Resnick D, Danzig L. Shoulder
Sato K. Cystic changes of the humeral head on impingement syndrome: radiographic evalua-
MR imaging - Relation to age and cuff-tears. Acta tion. Radiology. 1984;150(1):29–33. https://doi.
Orthop Scand. 1998;69(4):397–400. https://doi. org/10.1148/radiology.150.1.6689783.
org/10.3109/17453679808999054. 190. Kieft GJ, Bloem JL, Rozing PM, Obermann
178. Suluova F, Kanatli U, Ozturk BY, Esen E, Bolukbasi WR. Rotator cuff impingement syndrome: MR imag-
S. Humeral head cysts: association with rotator ing. Radiology. 1988;166(1 Pt 1):211–4. https://doi.
cuff tears and age. Eur J Orthop Surg Traumatol. org/10.1148/radiology.166.1.3336681.
2014;24(5):733–9. https://doi.org/10.1007/ 191. Kilcoyne RF, Reddy PK, Lyons F, Rockwood
s00590-013-1247-5. CA. Optimal plain film imaging of the shoul-
179. Studler U, Pfirrmann CW, Jost B, Rousson V, Hodler der impingement syndrome. Am J Roentgenol.
J, Zanetti M. Abnormalities of the lesser tuberos- 1989;153(4):795–7.
ity on radiography and MRI: association with sub- 192. Newhouse KE, el-Khoury GY, Nepola JV,
scapularis tendon lesions. AJR Am J Roentgenol. Montgomery WJ. The shoulder impingement view: a
2008;191(1):100–6. https://doi.org/10.2214/ fluoroscopic technique for the detection of subacro-
AJR.07.3056. mial spurs. AJR Am J Roentgenol. 1988;151(3):539–
180. Pan Y-W, Mok D, Tsiouri C, Chidambaram R. The 41. https://doi.org/10.2214/ajr.151.3.539.
association between radiographic greater tuberosity 193. Lee DH, Lee KH, Lopez-Ben R, Bradley EL. The
cystic change and rotator cuff tears: a study of 105 double-density sign: a radiographic finding sug-
consecutive cases. Shoulder Elbow. 2011;3(4):205–9. gestive of an os acromiale. J Bone Joint Surg Am.
https://doi.org/10.1111/j.1758-5740.2011.00143.x. 2004;86-A(12):2666–70.
181. Wissman RD, Ingalls J, Hendry D, Gorman D, 194. Omoumi P, Bafort AC, Dubuc JE, Malghem J,
Kenter K. Cysts within and adjacent to the lesser Vande Berg BC, Lecouvet FE. Evaluation of
tuberosity: correlation with shoulder arthroscopy. rotator cuff tendon tears: comparison of multi-
Skelet Radiol. 2012;41(9):1105–10. https://doi. detector CT arthrography and 1.5-T MR arthrog-
org/10.1007/s00256-012-1366-9. raphy. Radiology. 2012;264(3):812–22. https://doi.
182. Wissman R, Hendry D, Gorman D, Kapur S, Ingalls org/10.1148/radiol.12112062.
J, Ying J, Kenter K. Cysts within and adjacent to the 195. Mahmoud MK, Badran YM, Zaki HG, Ali AH. One-
lesser tuberosity: correlation with shoulder arthros- shot MR and MDCT arthrography of shoulder lesions
copy. Am J Roentgenol. 2010;194(5):1105. with arthroscopic correlation. Egypt J Radiol Nucl
183. Celikyay F, Yuksekkaya R, Deniz C, Inal S, Gokce Med. 2013;44(2):273–81. https://doi.org/10.1016/j.
E, Acu B. Locations of lesser tuberosity cysts and ejrnm.2013.01.002.
their association with subscapularis, supraspina- 196. Szymanski C, Staquet V, Deladerriere JY, Vervoort
tus, and long head of the biceps tendon disorders. T, Audebert S, Maynou C. Reproducibility
Acta Radiol. 2014;56(12):1494–500. https://doi. and reliability of subscapularis tendon assess-
org/10.1177/0284185114561821. ment using CT-arthrography. Orthop Traumatol-
184. Williams M, Lambert RG, Jhangri GS, Grace M, Sur. 2013;99(1):2–9. https://doi.org/10.1016/j.
Zelazo J, Wong B, Dhillon SS. Humeral head cysts otsr.2012.07.014.
and rotator cuff tears: an MR arthrographic study. 197. Charousset C, Bellaiche L, Duranthon LD,
Skelet Radiol. 2006;35(12):909–14. https://doi. Grimberg J. Accuracy of CT arthrography in
org/10.1007/s00256-006-0157-6. the assessment of tears of the rotator cuff. J
185. Jin W, Ryu KN, Park YK, Lee WK, Ko SH, Yang Bone Joint Surg. 2005;87b(6):824–8. https://doi.
DM. Cystic lesions in the posterosuperior portion of org/10.1302/0301-620x.87b6.15836.
the humeral head on MR arthrography: correlations 198. Roy JS, Braen C, Leblond J, Desmeules F,
with gross and histologic findings in cadavers. AJR Dionne CE, MacDermid JC, Bureau NJ, Fremont
Am J Roentgenol. 2005;184(4):1211–5. https://doi. P. Diagnostic accuracy of ultrasonography, MRI and
org/10.2214/ajr.184.4.01841211. MR arthrography in the characterisation of rotator
186. Koh KH, Han KY, Yoon YC, Lee SW, Yoo JC. True cuff disorders: a meta-analysis. Br J Sports Med.
anteroposterior (Grashey) view as a screening radio- 2015;49(20):1316–28. https://doi.org/10.1136/
graph for further imaging study in rotator cuff tear. bjsports-2014-094148.
199. Wohlwend JR, van Holsbeeck M, Craig J, Shirazi K, 212. Bauer S, Wang A, Butler R, Fallon M, Nairn R,
Habra G, Jacobsen G, Bouffard JA. The association Budgeon C, Breidahl W, Zheng MH. Reliability of a
between irregular greater tuberosities and rotator 3 T MRI protocol for objective grading of supraspi-
cuff tears: a sonographic study. Am J Roentgenol. natus tendonosis and partial thickness tears. J Orthop
1998;171(1):229–33. Surg Res. 2014;9:128. https://doi.org/10.1186/
200. Farin PU, Jaroma H, Harju A, Soimakallio s13018-014-0128-x.
S. Shoulder impingement syndrome: sonographic 213. de Jesus JO, Parker L, Frangos AJ, Nazarian
evaluation. Radiology. 1990;176(3):845–9. https:// LN. Accuracy of MRI, MR arthrography, and
doi.org/10.1148/radiology.176.3.2202014. ultrasound in the diagnosis of rotator cuff
201. Bureau NJ, Beauchamp M, Cardinal E, Brassard tears: a meta-analysis. AJR Am J Roentgenol.
P. Dynamic sonography evaluation of shoulder 2009;192(6):1701–7. https://doi.org/10.2214/
impingement syndrome. AJR Am J Roentgenol. AJR.08.1241.
2006;187(1):216–20. https://doi.org/10.2214/ 214. Farley TE, Neumann CH, Steinbach LS, Jahnke AJ,
AJR.05.0528. Petersen SS. Full-thickness tears of the rotator cuff
202. Daghir AA, Sookur PA, Shah S, Watson M. Dynamic of the shoulder: diagnosis with MR imaging. AJR
ultrasound of the subacromial-subdeltoid bursa Am J Roentgenol. 1992;158(2):347–51. https://doi.
in patients with shoulder impingement: a com- org/10.2214/ajr.158.2.1729796.
parison with normal volunteers. Skelet Radiol. 215. Lee JH, Yoon YC, Jee S. Diagnostic performance of
2012;41(9):1047–53. https://doi.org/10.1007/ indirect MR arthrography for the diagnosis of rotator
s00256-011-1295-z. cuff tears at 3.0 T. Acta Radiol. 2014;56(6):720–6.
203. Read JW, Perko M. Shoulder ultrasound: diagnostic https://doi.org/10.1177/0284185114537817.
accuracy for impingement syndrome, rotator cuff 216. Jung JY, Yoon YC, Yi SK, Yoo J, Choe
tear, and biceps tendon pathology. J Shoulder Elb BK. Comparison study of indirect MR arthrography
Surg. 1998;7(3):264–71. and direct MR arthrography of the shoulder. Skelet
204. Read JW, Perko M. Ultrasound diagnosis of Radiol. 2009;38(7):659–67. https://doi.org/10.1007/
subacromial impingement for lesions of the s00256-009-0660-7.
rotator cuff. Australas J Ultrasound Med. 217. Lee JH, Yoon YC, Jee S, Kwon JW, Cha JG, Yoo
2010;13(2):11–5. JC. Comparison of three-dimensional isotropic and
205. Khoury V, Cardinal E, Bureau NJ. Musculoskeletal two-dimensional conventional indirect MR arthrog-
sonography: a dynamic tool for usual and unusual raphy for the diagnosis of rotator cuff tears. Korean J
disorders. AJR Am J Roentgenol. 2007;188(1):W63– Radiol. 2014;15(6):771–80. https://doi.org/10.3348/
73. https://doi.org/10.2214/AJR.06.0579. kjr.2014.15.6.771.
206. Karjalainen PT, Soila K, Aronen HJ, Pihlajamaki 218. Dumontier C, Sautet A, Gagey O, Apoil A. Rotator
HK, Tynninen O, Paavonen T, Tirman PF. MR imag- interval lesions and their relation to coracoid
ing of overuse injuries of the Achilles tendon. AJR impingement syndrome. J Shoulder Elb Surg.
Am J Roentgenol. 2000;175(1):251–60. https://doi. 1999;8(2):130–5. https://doi.org/10.1016/
org/10.2214/ajr.175.1.1750251. S1058-2746(99)90005-8.
207. Krasnosselskaia LV, Fullerton GD, Dodd SJ, 219. Ferrick MR. Coracoid impingement - A case report
Cameron IL. Water in tendon: orientational anal- and review of the literature. Am J Sport Med.
ysis of the free induction decay. Magn Reson 2000;28(1):117–9.
Med. 2005;54(2):280–8. https://doi.org/10.1002/ 220. Gerber C, Terrier F, Ganz R. The role of the cora-
mrm.20540. coid process in the chronic impingement syndrome.
208. Berendsen HJC. Nuclear magnetic reso- J Bone Joint Surg. 1985;67(5):703–8.
nance study of collagen HYDRATION. J 221. Paulson MM, Watnik NF, Dines DM. Coracoid
Chem Phys. 1962;36(12):3297. https://doi. impingement syndrome, rotator interval recon-
org/10.1063/1.1732460. struction, and biceps tenodesis in the overhead
209. Gagey N, Quillard J, Gagey O, Meduri G, Bittoun J, athlete (Reprinted from Operative Techniques in
Lassau JP. Tendon of the normal supraspinatus mus- Sports Medicine, October, 2000). Orthop Clin
cle: correlations between MR imaging and histology. N Am. 2001;32(3):485. https://doi.org/10.1016/
Surg Radiol Anat. 1995;17(4):329–34. S0030-5898(05)70217-0.
210. Kjellin I, Ho CP, Cervilla V, Haghighi P, Kerr R, 222. Martetschlager F, Rios D, Boykin RE, Giphart JE,
Vangness CT, Friedman RJ, Trudell D, Resnick de Waha A, Millett PJ. Coracoid impingement: cur-
D. Alterations in the supraspinatus tendon at MR rent concepts. Knee surgery, sports traumatology.
imaging: correlation with histopathologic findings in Arthroscopy. 2012;20(11):2148–55. https://doi.
cadavers. Radiology. 1991;181(3):837–41. https:// org/10.1007/s00167-012-2013-7.
doi.org/10.1148/radiology.181.3.1947107. 223. Goldthwait JE. An anatomic and mechanical study
211. Tuite MJ. Magnetic resonance imaging of rota- of the shoulder-joint, explaining many of the cases
tor cuff disease and external impingement. Magn of painful shoulder, many of the recurrent disloca-
Reson Imaging Clin N Am. 2012;20(2):187–200, ix. tions, and many of the cases of brachial neuralgias
https://doi.org/10.1016/j.mric.2012.01.011. or neuritis. J Bone Joint Surg. 1909;s2-6(4):579.
224. Arrigoni P, Brady PC, Burkhart SS. Calcific ten- 239. Richards DP, Burkhart SS, Campbell SE. Relation
donitis of the subscapularis tendon causing sub- between narrowed coracohumeral distance and sub-
coracoid stenosis and coracoid impingement. scapularis tears. Arthroscopy. 2005;21(10):1223–8.
Arthroscopy. 2006;22(10):1139 e1131–3. https:// https://doi.org/10.1016/j.arthro.2005.06.015.
doi.org/10.1016/j.arthro.2005.06.028. 240. Friedman RJ, Bonutti PM, Genez B. Cine mag-
225. Franceschi F, Longo UG, Ruzzini L, Rizzello G, netic resonance imaging of the subcoracoid region.
Denaro V. Arthroscopic management of calcific ten- Orthopedics. 1998;21(5):545–8.
dinitis of the subscapularis tendon. Knee Surg Sports 241. Giaroli EL, Major NM, Lemley DE, Lee
Traumatol Arthrosc. 2007;15(12):1482–5. https:// J. Coracohumeral interval imaging in subcora-
doi.org/10.1007/s00167-007-0340-x. coid impingement syndrome on MRI. AJR Am
226. Ko JY, Shih CH, Chen WJ, Yamamoto R. Coracoid J Roentgenol. 2006;186(1):242–6. https://doi.
impingement caused by a ganglion from the sub- org/10.2214/AJR.04.0830.
scapularis tendon. A case report. J Bone Joint Surg. 242. Lo IK, Parten PM, Burkhart SS. Combined subcora-
1994;76(11):1709–11. coid and subacromial impingement in association
227. Peidro L, Serra A, Suso S. Subcoracoid impinge- with anterosuperior rotator cuff tears: An arthroscopic
ment after ossification of the subscapularis tendon. approach. Arthroscopy. 2003;19(10):1068–78.
J Shoulder Elb Surg. 1999;8(2):170–1. https://doi.org/10.1016/j.arthro.2003.10.016.
228. Terabayashi N, Fukuta M, Ito Y, Takigami I, 243. Nove-Josserand L, Boulahia A, Levigne C, Noel E,
Nishimoto Y, Shimizu K. Shoulder impingement Walch G. Coraco-humeral space and rotator cuff
syndrome due to a ganglion cyst below the cora- tears. Rev Chir Orthop Reparatrice Appar Mot.
coacromial ligament: a case report. J Bone Joint 1999;85(7):677–83.
Surg. 2011;93(8):e36. https://doi.org/10.2106/ 244. Lo IKY, Burkhart SS. Arthroscopic coraco-
JBJS.J.00810. plasty through the rotator interval. Arthroscopy.
229. Patte D. The subcoracoid impingement. Clin Orthop 2003;19(6):667–71. https://doi.org/10.1016/
Relat Res. 1990;254:55–9. S0749-8063(03)00219-6.
230. Radas CB, Pieper HG. The coracoid impingement 245. Nove-Josserand L, Edwards TB, O'Connor DP,
of the subscapularis tendon: a cadaver study. J Walch G. The acromiohumeral and coracohumeral
Shoulder Elb Surg. 2004;13(2):154–9. https://doi. intervals are abnormal in rotator cuff tears with
org/10.1016/S1058274603003124. muscular fatty degeneration. Clin Orthop Relat Res.
231. Kragh JF Jr, Doukas WC, Basamania CJ. Primary 2005;433:90–6.
coracoid impingement syndrome. Am J Orthop (Belle 246. Walz DM, Miller TT, Chen S, Hofman J. MR imag-
Mead NJ). 2004;33(5):229–32.. discussion 232 ing of delamination tears of the rotator cuff tendons.
232. Okoro T, Reddy VR, Pimpelnarkar A. Coracoid Skelet Radiol. 2007;36(5):411–6. https://doi.
impingement syndrome: a literature review. Curr org/10.1007/s00256-006-0265-3.
Rev Musculoskelet Med. 2009;2(1):51–5. https:// 247. Deutsch A, Altchek DW, Veltri DM, Potter HG,
doi.org/10.1007/s12178-009-9044-9. Warren RF. Traumatic tears of the subscapularis ten-
233. Dines DM, Warren RF, Inglis AE, Pavlov H. The don. Clinical diagnosis, magnetic resonance imaging
coracoid impingement syndrome. J Bone Joint Surg. findings, and operative treatment. Am J Sports Med.
1990;72(2):314–6. 1997;25(1):13–22.
234. Gerber C, Terrier F, Zehnder R, Ganz R. The subcor- 248. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint
acoid space. An anatomic study. Clin Orthop Relat B, Gobezie R. Structural integrity and clinical out-
Res. 1987;215:132–8. comes after arthroscopic repair of isolated subscapu-
235. Masala S, Fanucci E, Maiotti M, Nardocci M, laris tears. J Bone Joint Surg. 2007;89(6):1184–93.
Gaudioso C, Apruzzese A, Di Mario M, Simonetti https://doi.org/10.2106/JBJS.F.00007.
G. Impingement syndrome of the shoulder. 249. Fox J, Romeo AA Arthroscopic subscapularis repair.
Clinical data and radiologic findings. Radiol Med. In: Annual Meeting of the American Academy of
1995;89(1–2):18–21. Orthopaedic Surgeons, New Orleans, LA, 2003.
236. Finnoff JT, Thompson JM, Collins M, Dahm 250. Osti L, Soldati F, Buono AD, Buda M. Arthroscopic
D. Subcoracoid bursitis as an unusual cause of pain- repair of the subscapularis tendon: indications, limits
ful anterior shoulder snapping in a weight lifter. and technical features. Muscles Ligaments Tendons
Am J Sports Med. 2010;38(8):1687–92. https://doi. J. 2013;3(3):213–9.
org/10.1177/0363546510369546. 251. Kim SJ, Jung M, Lee JH, Kim C, Chun
237. Drakes S, Thomas S, Kim S, Guerrero L, Lee YM. Arthroscopic repair of anterosuperior rotator
SW. Ultrasonography of subcoracoid bursal cuff tears: in-continuity technique vs. disruption
impingement syndrome. Pm&R. 2015;7(3):329–33. of subscapularis-supraspinatus tear margin: com-
https://doi.org/10.1016/j.pmrj.2014.09.015. parison of clinical outcomes and structural integ-
238. Bonutti PM, Norfray JF, Friedman RJ, Genez rity between the two techniques. J Bone Joint Surg
BM. Kinematic Mri of the Shoulder. J Comput Am. 2014;96(24):2056–61. https://doi.org/10.2106/
Assist Tomogr. 1993;17(4):666–9. JBJS.N.00293.
252. Visona E, Cerciello S, Godeneche A, Neyton L, 265. Wright RW, Steger-May K, Klein SE.
Fessy MH, Nove-Josserand L. The "comma sign": Radiographic findings in the shoulder and elbow of
an anatomical investigation (dissection of the rota- major league baseball pitchers. Am J Sport Med.
tor interval in 14 cadaveric shoulders). Surgical 2007;35(11):1839–43. https://doi.org/10.1177/
Radiol Anatomy. 2015;37(7):793–8. https://doi. 0363546507304493.
org/10.1007/s00276-015-1420-0. 266. Bennett GE. Shoulder and elbow lesions distinctive
253. Lo IK, Burkhart SS. The comma sign: An of baseball players. Ann Surg. 1947;126(1):107–10.
arthroscopic guide to the torn subscapularis ten- 267. Wright RW, Paletta GA Jr. Prevalence of the Bennett
don. Arthroscopy. 2003;19(3):334–7. https://doi. lesion of the shoulder in major league pitchers. Am J
org/10.1053/jars.2003.50080. Sports Med. 2004;32(1):121–4.
254. Jung JY, Yoon YC, Cha DI, Yoo JC, Jung JY. The 268. Nakagawa S, Yoneda M, Hayashida K, Mizuno N,
"bridging sign": a MR finding for combined full- Yamada S. Posterior shoulder pain in throwing ath-
thickness tears of the subscapularis tendon and the letes with a Bennett lesion: Factors that influence
supraspinatus tendon. Acta Radiol. 2013;54(1):83– throwing pain. J Shoulder Elb Surg. 2006;15(1):72–
8. https://doi.org/10.1258/ar.2012.120353. 7. https://doi.org/10.1016/j.jse.2005.05.010.
255. Walch G, Boileau P, Noel E, Donell ST. Impingement 269. Ferrari JD, Ferrari DA, Coumas J, Pappas
of the deep surface of the supraspinatus tendon on the AM. Posterior ossification of the shoulder - the
posterosuperior glenoid rim: An arthroscopic study. bennett lesion - etiology, diagnosis, and treatment.
J Shoulder Elb Surg. 1992;1(5):238–45. https://doi. Am J Sport Med. 1994;22(2):171–6. https://doi.
org/10.1016/S1058-2746(09)80065-7. org/10.1177/036354659402200204.
256. Jobe CM. Posterior superior glenoid impinge- 270. Yablon CM, Bedi A, Morag Y, Jacobson JA.
ment: expanded spectrum. Arthroscopy. Ultrasonography of the shoulder with arthroscopic
1995;11(5):530–6. correlation. Clin Sports Med. 2013;32(3):391–408.
257. Halbrecht JL, Tirman P, Atkin D. Internal impinge- https://doi.org/10.1016/j.csm.2013.03.001.
ment of the shoulder: comparison of findings between 271. Thomas SJ, Swanik CB, Higginson JS, Kaminski
the throwing and nonthrowing shoulders of college TW, Swanik KA, Bartolozzi AR, Abboud JA,
baseball players. Arthroscopy. 1999;15(3):253–8. Nazarian LN. A bilateral comparison of posterior
https://doi.org/10.1016/S0749-8063(99)70030-7. capsule thickness and its correlation with glenohu-
258. McFarland EG, Hsu CY, Neira C, O'Neil meral range of motion and scapular upward rota-
O. Internal impingement of the shoulder: a clini- tion in collegiate baseball players. J Shoulder Elb
cal and arthroscopic analysis. J Shoulder Elb Surg. 2011;20(5):708–16. https://doi.org/10.1016/j.
Surg. 1999;8(5):458–60. https://doi.org/10.1016/ jse.2010.08.031.
S1058-2746(99)90076-9. 272. Kirchhoff C, Imhoff AB. Posterosuperior and
259. Walch G, Liotard JP, Boileau P, Noel E. Postero- anterosuperior impingement of the shoulder in
superior glenoid impingement. Another impinge- overhead athletes-evolving concepts. Int Orthop.
ment of the shoulder. J Radiol. 1993;74(1):47–50. 2010;34(7):1049–58. https://doi.org/10.1007/
260. Jobe FW, Giangarra CE, Kvitne RS, Glousman s00264-010-1038-0.
RE. Anterior capsulolabral reconstruction of 273. Giaroli EL, Major NM, Higgins LD. MRI of
the shoulder in athletes in overhand sports. Am internal impingement of the shoulder. AJR Am
J Sports Med. 1991;19(5):428–34. https://doi. J Roentgenol. 2005;185(4):925–9. https://doi.
org/10.1177/036354659101900502. org/10.2214/AJR.04.0971.
261. Mihata T, McGarry MH, Neo M, Ohue M, Lee 274. Tirman PFJ, Bost FW, Garvin GJ, Peterfy CG, Mall
TQ. Effect of anterior capsular laxity on horizon- JC, Steinbach LS, Feller JF, Crues JV. Posterosuperior
tal abduction and forceful internal impingement in glenoid impingement of the shoulder - findings at
a cadaveric model of the throwing shoulder. Am Mr-imaging and Mr arthrography with Arthroscopic
J Sports Med. 2015;43(7):1758–63. https://doi. correlation. Radiology. 1994;193(2):431–6.
org/10.1177/0363546515582025. 275. Smith TO, Drew BT, Toms AP. A meta-analysis of
262. Burkhart SS, Morgan CD, Kibler WB. The disabled the diagnostic test accuracy of MRA and MRI for
throwing shoulder: spectrum of pathology Part I: the detection of glenoid labral injury. Arch Orthop
pathoanatomy and biomechanics. Arthroscopy. Trauma Surg. 2012;132(7):905–19. https://doi.
2003;19(4):404–20. https://doi.org/10.1053/ org/10.1007/s00402-012-1493-8.
jars.2003.50128. 276. Chang EY, Fliszar E, Chung CB. Superior
263. Levitz CL, Dugas J, Andrews JR. The use of labrum anterior and posterior lesions and micro-
arthroscopic thermal capsulorrhaphy to treat inter- instability. Magn Reson Imaging Clin N Am.
nal impingement in baseball players. Arthroscopy. 2012;20(2):277–94., x-xi. https://doi.org/10.1016/j.
2001;17(6):573–7. https://doi.org/10.1053/ mric.2012.01.002.
jars.2001.24853. 277. Tehranzadeh AD, Fronek J, Resnick D. Posterior
264. Mithöfer K, Fealy S, Altchek DW. Arthroscopic capsular fibrosis in professional baseball pitch-
Treatment of Internal Impingement of the Shoulder. ers: case series of MR arthrographic findings in
Tech Should Elbow Surg. 2004;5(2):66–75. six patients with glenohumeral internal rotational
deficit. Clin Imaging. 2007;31(5):343–8. https://doi. 290. Barile A, Lanni G, Conti L, Mariani S, Calvisi V,
org/10.1016/j.clinimag.2007.05.005. Castagna A, Rossi F, Masciocchi C. Lesions of the
278. Tuite MJ, Petersen BD, Wise SM, Fine JP, Kaplan biceps pulley as cause of anterosuperior impinge-
LD, Orwin JF. Shoulder MR arthrography of the pos- ment of the shoulder in the athlete: potentials and
terior labrocapsular complex in overhead throwers limits of MR arthrography compared with arthros-
with pathologic internal impingement and internal copy. Radiol Med. 2013;118(1):112–22. https://doi.
rotation deficit. Skelet Radiol. 2007;36(6):495–502. org/10.1007/s11547-012-0838-2.
https://doi.org/10.1007/s00256-007-0278-6. 291. Chandnani VP, Gagliardi JA, Murnane TG,
279. Jung JY, Ha DH, Lee SM, Blacksin MF, Kim KA, Bradley YC, DeBerardino TA, Spaeth J, Hansen
Kim JW. Displaceability of SLAP lesion on shoul- MF. Glenohumeral ligaments and shoulder cap-
der MR arthrography with external rotation posi- sular mechanism: evaluation with MR arthrogra-
tion. Skelet Radiol. 2011;40(8):1047–55. https://doi. phy. Radiology. 1995;196(1):27–32. https://doi.
org/10.1007/s00256-011-1134-2. org/10.1148/radiology.196.1.7784579.
280. Saleem AM, Lee JK, Novak LM. Usefulness of 292. Nakata W, Katou S, Fujita A, Nakata M, Lefor
the abduction and external rotation views in shoul- AT, Sugimoto H. Biceps pulley: normal anat-
der MR arthrography. AJR Am J Roentgenol. omy and associated lesions at MR arthrography.
2008;191(4):1024–30. https://doi.org/10.2214/ Radiographics. 2011;31(3):791–810. https://doi.
AJR.07.3962. org/10.1148/rg.313105507.
281. Mulyadi E, Harish S, O'Neill J, Rebello R. MRI of 293. Familiari F, Gonzalez-Zapata A, Iannò B, Galasso
impingement syndromes of the shoulder. Clin Radiol. O, Gasparini G, McFarland E. Is acromioplasty
2009;64(3):307–18. https://doi.org/10.1016/j. necessary in the setting of full-thickness rota-
crad.2008.08.013. tor cuff tears? A systematic review. J Orthopaed
282. Gerber C, Sebesta A. Impingement of the deep sur- Traumatol. 2015;16:1–8. https://doi.org/10.1007/
face of the subscapularis tendon and the reflection s10195-015-0353-z.
pulley on the anterosuperior glenoid rim: a prelimi- 294. Ensor KL, Kwon YW, Dibeneditto MR, Zuckerman
nary report. J Shoulder Elb Surg. 2000;9(6):483–90. JD, Rokito AS. The rising incidence of rotator cuff
https://doi.org/10.1067/mse.2000.109322. repairs. J Shoulder Elb Surg. 2013;22(12):1628–32.
283. Struhl S. Anterior internal impingement: https://doi.org/10.1016/j.jse.2013.01.006.
an arthroscopic observation. Arthroscopy. 295. Chen M, Xu W, Dong Q, Huang Q, Xie Z, Mao
2002;18(1):2–7. Y. Outcomes of single-row versus double-row
284. Habermeyer P, Magosch P, Pritsch M, Scheibel arthroscopic rotator cuff repair: a systematic review
MT, Lichtenberg S. Anterosuperior impinge- and meta-analysis of current evidence. Arthroscopy.
ment of the shoulder as a result of pulley lesions: 2013;29(8):1437–49. https://doi.org/10.1016/j.
a prospective arthroscopic study. J Shoulder Elb arthro.2013.03.076.
Surg. 2004;13(1):5–12. https://doi.org/10.1016/j. 296. McElvany MD, McGoldrick E, Gee AO,
jse.2003.09.013. Neradilek MB, Matsen FA 3rd. Rotator cuff
285. Garofalo R, Karlsson J, Nordenson U, Cesari E, repair: published evidence on factors associated
Conti M, Castagna A. Anterior-superior internal with repair integrity and clinical outcome. Am
impingement of the shoulder: an evidence-based J Sports Med. 2015;43(2):491–500. https://doi.
review. Knee Surg Sports Traumatol Arthrosc. org/10.1177/0363546514529644.
2010;18(12):1688–93. https://doi.org/10.1007/ 297. Millett PJ, Warth RJ, Dornan GJ, Lee JT, Spiegl
s00167-010-1232-z. UJ. Clinical and structural outcomes after
286. Krzycki J, Tischer T, Imhoff AB. The para-shoulder: arthroscopic single-row versus double-row rotator
lesions of the anterior-superior complex (Labrum, cuff repair: a systematic review and meta-analysis
SGHL, SSC) and their arthroscopic treatment. Z of level I randomized clinical trials. J Shoulder Elb
Orthop Ihre Grenzgeb. 2006;144(5):446–8. https:// Surg. 2014;23(4):586–97. https://doi.org/10.1016/j.
doi.org/10.1055/s-2006-954403. jse.2013.10.006.
287. Valadie AL, Jobe CM, Pink MM, Ekman EF, Jobe 298. Ide J, Maeda S, Takagi K. Arthroscopic transten-
FW. Anatomy of provocative tests for impinge- don repair of partial-thickness articular-side tears
ment syndrome of the shoulder. J Shoulder Elb of the rotator cuff: anatomical and clinical study.
Surg. 2000;9(1):36–46. https://doi.org/10.1016/ Am J Sports Med. 2005;33(11):1672–9. https://doi.
S1058-2746(00)90008-9. org/10.1177/0363546505277141.
288. Pappas GP, Blemker SS, Beaulieu CF, McAdams TR, 299. Lo IK, Burkhart SS. Transtendon arthroscopic
Whalen ST, Gold GE. In vivo anatomy of the Neer repair of partial-thickness, articular surface tears of
and Hawkins sign positions for shoulder impinge- the rotator cuff. Arthroscopy. 2004;20(2):214–20.
ment. J Shoulder Elb Surg. 2006;15(1):40–9. https:// https://doi.org/10.1016/j.arthro.2003.11.042.
doi.org/10.1016/j.jse.2005.04.007. 300. Iyengar JJ, Porat S, Burnett KR, Marrero-Perez
289. Baumann B, Genning K, Bohm D, Rolf O, Gohlke L, Hernandez VH, Nottage WM. Magnetic reso-
F. Arthroscopic prevalence of pulley lesions in 1007 nance imaging tendon integrity assessment after
consecutive patients. J Shoulder Elb Surg. arthroscopic partial-thickness rotator cuff repair.
2008;17(1):14–20. https://doi.org/10.1016/j.jse.2007. Arthroscopy. 2011;27(3):306–13. https://doi.
04.011. org/10.1016/j.arthro.2010.08.017.
301. Sun L, Zhang Q, Ge H, Sun Y, Cheng B. Which is 314. Duc SR, Mengiardi B, Pfirrmann CW, Jost B,
the best repair of articular-sided rotator cuff tears: Hodler J, Zanetti M. Diagnostic performance of
a meta-analysis. J Orthop Surg Res. 2015;10(1):84. MR arthrography after rotator cuff repair. AJR Am
https://doi.org/10.1186/s13018-015-0224-6. J Roentgenol. 2006;186(1):237–41. https://doi.
302. Wolf EM, Pennington WT, Agrawal V. Arthroscopic org/10.2214/AJR.04.1818.
side-to-side rotator cuff repair. Arthroscopy. 315. Kim S-J, Kim S-H, Lim S-H, Chun Y-M. Use of mag-
2005;21(7):881–7. https://doi.org/10.1016/j. netic resonance arthrography to compare clinical fea-
arthro.2005.03.014. tures and structural integrity after arthroscopic repair
303. Burkhart SS. The principle of margin convergence in of bursal versus articular side partial-thickness rota-
rotator cuff repair as a means of strain reduction at the tor cuff tears. Am J Sports Med. 2013;41(9):2041–7.
tear margin. Ann Biomed Eng. 2004;32(1):166–70. 316. Tudisco C, Bisicchia S, Savarese E, Fiori R,
304. Suchenski M, McCarthy MB, Chowaniec D, Bartolucci DA, Masala S, Simonetti G. Single-row
Hansen D, McKinnon W, Apostolakos J, Arciero R, vs. double-row arthroscopic rotator cuff repair:
Mazzocca AD. Material properties and composition clinical and 3 Tesla MR arthrography results. BMC
of soft-tissue fixation. Arthroscopy. 2010;26(6):821– Musculoskelet Disord. 2013;14:43. https://doi.
31. https://doi.org/10.1016/j.arthro.2009.12.026. org/10.1186/1471-2474-14-43.
305. Apreleva M, Ozbaydar M, Fitzgibbons PG, Warner 317. Crim J, Burks R, Manaster BJ, Hanrahan C, Hung
JJ. Rotator cuff tears: the effect of the reconstruc- M, Greis P. Temporal evolution of MRI findings
tion method on three-dimensional repair site area. after arthroscopic rotator cuff repair. AJR Am
Arthroscopy. 2002;18(5):519–26. https://doi. J Roentgenol. 2010;195(6):1361–6. https://doi.
org/10.1053/jars.2002.32930. org/10.2214/AJR.10.4436.
306. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun 318. Spielmann AL, Forster BB, Kokan P, Hawkins RH,
BJ, Lee TQ. Part I: footprint contact characteristics Janzen DL. Shoulder after rotator cuff repair: MR
for a transosseous-equivalent rotator cuff repair tech- imaging findings in asymptomatic individuals--initial
nique compared with a double-row repair technique. experience. Radiology. 1999;213(3):705–8. https://
J Shoulder Elb Surg. 2007;16(4):461–8. https://doi. doi.org/10.1148/radiology.213.3.r99dc09705.
org/10.1016/j.jse.2006.09.010. 319. Owen RS, Iannotti JP, Kneeland JB, Dalinka
307. Denard PJ, Burkhart SS. The evolution of suture MK, Deren JA, Oleaga L. Shoulder after surgery:
anchors in arthroscopic rotator cuff repair. MR imaging with surgical validation. Radiology.
Arthroscopy. 2013;29(9):1589–95. https://doi. 1993;186(2):443–7. https://doi.org/10.1148/
org/10.1016/j.arthro.2013.05.011. radiology.186.2.8421748.
308. Park MC, Elattrache NS, Ahmad CS, Tibone JE. 320. Koh KH, Kang KC, Lim TK, Shon MS, Yoo
“Transosseous-equivalent” rotator cuff repair tech- JC. Prospective randomized clinical trial of single-
nique. Arthroscopy. 2006;22(12):1360 e1361–5. versus double-row suture anchor repair in 2- to 4-cm
https://doi.org/10.1016/j.arthro.2006.07.017. rotator cuff tears: clinical and magnetic resonance
309. Voos JE, Barnthouse CD, Scott AR. Arthroscopic imaging results. Arthroscopy. 2011;27(4):453–62.
rotator cuff repair: techniques in 2012. Clin Sports https://doi.org/10.1016/j.arthro.2010.11.059.
Med. 2012;31(4):633–44. https://doi.org/10.1016/j. 321. Franceschi F, Ruzzini L, Longo UG, Martina
csm.2012.07.002. FM, Zobel BB, Maffulli N, Denaro V. Equivalent
310. Garofalo R, Castagna A, Borroni M, Krishnan clinical results of arthroscopic single-row and
SG. Arthroscopic transosseous (anchorless) rotator double-row suture anchor repair for rotator
cuff repair. Knee Surg Sports Traumatol Arthrosc. cuff tears: a randomized controlled trial. Am J
2012;20(6):1031–5. https://doi.org/10.1007/ Sports Med. 2007;35(8):1254–60. https://doi.
s00167-011-1725-4. org/10.1177/0363546507302218.
311. Salata MJ, Sherman SL, Lin EC, Sershon RA, Gupta 322. Cho NS, Yi JW, Lee BG, Rhee YG. Retear pat-
A, Shewman E, Wang VM, Cole BJ, Romeo AA, terns after arthroscopic rotator cuff repair:
Verma NN. Biomechanical evaluation of transos- single-row versus suture bridge technique. Am
seous rotator cuff repair: do anchors really matter? J Sports Med. 2010;38(4):664–71. https://doi.
Am J Sports Med. 2013;41(2):283–90. https://doi. org/10.1177/0363546509350081.
org/10.1177/0363546512469092. 323. Hayashida K, Tanaka M, Koizumi K, Kakiuchi
312. Prickett WD, Teefey SA, Galatz LM, Calfee RP, M. Characteristic retear patterns assessed by
Middleton WD, Yamaguchi K. Accuracy of ultra- magnetic resonance imaging after arthroscopic
sound imaging of the rotator cuff in shoulders that double-row rotator cuff repair. Arthroscopy.
are painful postoperatively. J Bone Joint Surg Am. 2012;28(4):458–64. https://doi.org/10.1016/j.
2003;85-A(6):1084–9. arthro.2011.09.006.
313. Lee KW, Yang DS, Chun TJ, Bae KW, Choy WS, 324. Saccomanno MF, Cazzato G, Fodale M, Sircana
Park HJ. A comparison of conventional ultrasonog- G, Milano G. Magnetic resonance imaging cri-
raphy and arthrosonography in the assessment of teria for the assessment of the rotator cuff after
cuff integrity after rotator cuff repair. Clin Orthop repair: a systematic review. Knee Surg Sports
Surg. 2014;6(3):336–42. https://doi.org/10.4055/ Traumatol Arthrosc. 2015;23(2):423–42. https://doi.
cios.2014.6.3.336. org/10.1007/s00167-014-3486-3.
Imaging Diagnosis of Biceps
Tendon and Rotator Interval 6
Pathology
Luis S. Beltran, Eric Ledermann, Sana Ali,

and Javier Beltran
6.1 Introduction of the subscapularis tendon inferiorly, and the

coracoid process at its base (Fig. 6.1).
Rotator interval pathology is associated with biceps The rotator interval capsule (RIC), the most
instability, glenohumeral instability, and adhesive anterior-superior portion of the glenohumeral joint
capsulitis, all of which can be challenging to clini- capsule, traverses the rotator interval and is rein-
cally diagnose and treat. The complex anatomy and forced by two ligaments, one internally by the
orientation of the structures in this region within a superior glenohumeral ligament (SGHL) and the
relatively small space can make it difficult to evalu- other externally by the coracohumeral ligament
ate by imaging; however, improvements in MR (CHL). Distally, the RIC joins the CHL and SGHL
technology have better allowed detection of disease along the medial and lateral aspects of the bicipital
in this region. Furthermore, it is important to real- groove maintaining the long head of the biceps
ize that the rotator interval is not routinely evalu- tendon (LHBT) in normal anatomical location.
ated upon arthroscopic investigation unless the The CHL is a relatively constant structure only
clinical examination or imaging points to pathol- found to be hypoplastic or absent in 6% (4 of 63)
ogy at this level. Imaging, therefore, plays a critical of shoulder dissections [1, 2]. It originates along
role in helping the clinician make the diagnosis and the lateral aspect of the base of the coracoid pro-
initiate appropriate treatment. cess of the scapula just abutting the external sur-
face of the glenohumeral joint. The CHL is
formed by two bands: a smaller band, medially,
6.2 Normal Anatomy and a larger band, laterally, which are not always
of the Rotator Interval seen with clear distinction [1]. The medial band of
the CHL (MCHL) merges distally with the SGHL
A triangular space, the rotator cuff interval, to form a ligament (SGHL-MCHL) complex. The
resides in the anterior-superior aspect of the complex then surrounds the medial and inferior
shoulder bounded by the anterior fibers of the aspects of the intra- articular portion of LHBT
supraspinatus tendon superiorly, the cranial fibers forming a sling-like structure that cradles the
biceps tendon, before inserting on the lesser
tuberosity. At the lesser tuberosity insertion it then
L. S. Beltran (*) merges with the RIC along with the superior
Department of Radiology, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
fibers of the subscapularis tendon. The lateral
e-mail: lbeltran@bwh.harvard.edu band of the CHL (LCHL) surrounds the superior
E. Ledermann · S. Ali · J. Beltran
and lateral aspects of the intra-articular LHBT
Department of Radiology, Maimonides Medical before inserting on the greater tuberosity. At that
Center, Brooklyn, NY, USA

128 L. S. Beltran et al.
Fig. 6.1 Normal

anatomy of rotator a
interval. (a) Illustration
and (b) sagittal
fat-saturated
T1-weighted MR
arthrogram image
demonstrate rotator
interval structures
including long head of
the biceps tendon
(LHBT), coracohumeral
ligament (CHL),
superior glenohumeral
ligament (SGHL),
subscapularis tendon
(SSC), supraspinatus
tendon (SPN), and
rotator interval capsule
(RIC). In the illustration,
RIC, SGHL, CHL, SSC,
and SPN are partially
resected to visualize
underlying structures.
COR, coracoid process;
IG, intertubercular
groove; SGHLMCHL, b
superior glenohumeral
ligament-medial
coracohumeral ligament
complex. Illustration and
MR image reprinted
with permission from
Beltran LS, Beltran
J. Biceps and rotator
interval: imaging update.
Semin Musculoskelet
Radiol. Thieme Medical
Publishers;
2014;18:425–35
point, it merges with the anterior margin of the tion to, the LHBT within the rotator interval
supraspinatus tendon. The coracohumeral liga- forming a ligament (SGHL-MCHL) complex
ment remains lax and unengaged with the arm in with the CHL. This complex surrounds and cra-
internal rotation and adduction. dles the biceps tendon and maintains its position.
The SGHL, like the CHL, is rarely absent, Distally, the SGHL inserts into the fovea capitis
only reported unseen in 3% of patients at arthros- of the humerus, a small depression above the
copy [3]. Its origin is the supraglenoid tubercle lesser tuberosity, further contributing to the sta-
which resides just anterior to the origin of the bility of the LHBT.
LHBT; however variable origins do include the The intra-articular portion of the LHBT origi-
superior labrum, LHBT, and middle glenohu- nates from either the supraglenoid tubercle of the
meral ligament [3]. The SGHL courses anterior glenoid osseous rim, the posterosuperior labrum,
and inferior to, and maintains close approxima- or a combination of both [4]. Variant anatomy of
6 Imaging Diagnosis of Biceps Tendon and Rotator Interval Pathology 129
the distal biceps brachii muscle is common, with greater tuberosities at the intertubercular groove.
the literature reporting 9–23% variance in multi- The function and normal anatomical position of
ple supernumerary heads [5, 6]. Proximal anoma- the LHBT depend greatly on the integrity of these
lies are quite rare with respect to the intra-articular surrounding support structures including the
LHBT6 (Fig. 6.2). The LHBT courses obliquely static stabilizers (RIC, CHL, SGHL) and the
through the rotator interval making a 30- to dynamic stabilizers (supraspinatus and subscapu-
45-degree turn along the anterior surface of the laris tendons). Together, these stabilizing struc-
humeral head before exiting the joint. It then tures comprise the complex commonly referred
resides with the space between the lesser and to as the biceps reflection pulley [1, 7]. The
a b
Fig. 6.2 Supernumerary tendons of biceps brachii mus- biceps tendon (SHBT) (curved dashed arrow in a and b).
cle. (a, b) Axial fat-saturated and (c) sagittal fat-satu- The supernumerary tendon originates from superior
rated T2 MR images demonstrate three distinct tendon aspect of rotator interval capsule, which is a variant ana-
slips of biceps brachii muscle in proximal arm including tomical origin (solid arrow in c). The other intra-articu-
a supernumerary third tendon (solid arrow in a and b) lar LHBT originates from the supraglenoid tubercle of
located lateral to long head of biceps tendon (LHBT) glenoid (dashed arrow in c), which is the most common
(straight dashed arrow in a and b) and short head of anatomical origin
biceps reflection pulley is responsible for limit- disease and biceps tenotomy or tenodesis for
ing medial subluxation of the LHBT when the more advanced disease [13] (Fig. 6.3). Biceps
arm is abducted and externally rotated. Injuries to tenotomy includes the resection of the intra-
any of the components, mentioned above, are articular portion of the biceps tendon, whereas
referred to as “pulley lesions” [8, 9]. biceps tenodesis involves resection of the intra-
articular portion of the biceps tendon and reat-
tachment of the distal tendon stump to the humeral
6.3 Pathology of the Rotator neck or subpectoral proximal humeral shaft.
Interval
6.3.1 Biceps Tendon Pathology 6.3.2 Biceps Reflection Pulley Injury
Three categories of tendinopathy exist of the Position of the biceps tendon within the rotator
LHBT: impingement tendinopathy, tendinopathy interval and bicipital groove depends heavily on
with subluxation, and attrition tendinopathy [10]. the stability of the biceps reflection pulley. The
Impingement tendinopathy of the proximal biceps prevalence of biceps pulley lesions from
tendon is commonly associated with rotator cuff arthroscopic data is 7%, representing a consider-
pathology as a result of impingement between the able source of morbidity [15]. Traumatic and
head of the humerus, the acromion, and the cora- nontraumatic causes can lead to biceps reflection
cohumeral ligament during elevation and external pulley injury. Traumatic injuries usually result
rotation of the arm [11, 12]. Tendinopathy with from a fall on the outstretched arm in combina-
subluxation results from injury to the coracohu- tion with full external or internal rotation or a
meral ligament and superior glenohumeral liga- backward fall onto the hand or elbow [16].
ment [12]. Attrition tendinopathy, also described Nontraumatic injury generally occurs due to
as primary tendinitis [10, 13], is the result of new chronic repetitive overhand activity typically
local bone formation causing stenosis of the seen with throwing sports [17] such as baseball,
bicipital groove which may lead to adhesions. In a tennis, and volleyball. Injury to the biceps reflec-
study of 122 complete rotator cuff tears by Chen tion pulley may also occur in association with
et al. [11], the biceps long-head tendon was evalu- rotator cuff tears. In particular, far-anterior
ated via arthroscopy or open surgery, showing supraspinatus tendon footprint insertion and
that the incidence of biceps tendinitis was 41%, superior subscapularis footprint insertion (also
subluxation was 8%, dislocation was 10%, partial known as anterosuperior rotator cuff tears) tears
tear was 12%, and complete rupture was 5%. The may dissect to involve the CHL and SGHL,
typical clinical scenario of proximal biceps ten- respectively [1]. Injury to this region of the cuff
don injury is presentation with anterior shoulder may result in instability of the biceps tendon
pain and loss of forward arm flexion. When these resulting in biceps tendon subluxation or, worse,
symptoms are isolated, treatment is often conser- dislocation [17, 18].
vative with options including nonsteroidal anti- Clinically, biceps pulley injury can be chal-
inflammatory drugs (NSAIDS), physical therapy, lenging to diagnose and is often referred to as
and/or steroid injection near the biceps groove “hidden lesion” because it can be missed during
around the biceps tendon. Surgical treatment may open and arthroscopic examination [19]. Two
be necessary when symptoms are over 3 months separate but similar classification systems of
in duration, if conservative methods fail, or if biceps pulley injuries have been described by
there are other associated injuries to the rotator Habermeyer et al. and Bennett, respectively,
cuff or labrum [14]. In patients with impinge- which are based on arthroscopic studies [7, 20].
ment, surgical subacromial decompression is per- Injury to the biceps reflection pulley can result in
formed [12]. Direct therapy of the biceps tendon medial subluxation or dislocation of the biceps
includes shaving of the tendon in mild or early tendon toward the glenohumeral joint or take a
a b
c d
Fig. 6.3 Biceps tenotomy and tenodesis. (a) Preoperative suppressed proton density MR images. When a tenodesis is
illustration of incision sites for biceps tenotomy and tenode- performed, the same incisions are made in the biceps tendon
sis (dashed lines). Postoperative appearance of biceps tenot- (dashed lines in a) coupled with fixation devices (screw,
omy is demonstrated in (b) illustration and (c) coronal and anchor, or sutures) at the attachment of the distal portion of
(d) axial fat-suppressed T2 MR images demonstrating the biceps tendon to the humeral head (arrows in e, f, and g)
resection of the intra-articular biceps tendon at the level of or more distally along the subpectoral proximal humeral
the supraglenoid tubercle and humeral head (dashed lines in shaft (not shown). Labral tears, specifically, superior labrum
a). MRI normally shows a resected biceps tendon stump at anterior and posterior (SLAP) tears (curved arrows in a, b,
the level of the humeral head (solid straight arrow in b, c), and e), are a form of concurrent injury leading to the need
postoperative changes at the supraglenoid tubercle where for performing biceps tenotomy/tenodesis in the treatment
the tendon insertion has been resected (dashed arrow in c), of biceps tendon pathology. Illustrations reprinted with per-
and non-visualization of the intra-articular portion of the mission from Beltran LS, Beltran J. Biceps and rotator inter-
long head of the biceps tendon with an empty bicipital val: imaging update. Semin Musculoskelet Radiol. Thieme
groove (arrow in d). Biceps tenodesis is demonstrated in (e) Medical Publishers; 2014;18:425–35
illustration and (f) coronal proton density and (g) axial fat-
e f
Fig. 6.3 (continued)
more anterior extra-articular course depending 6.3.3 otator Interval Laxity

R
on which structures of the biceps reflection pul- and Instability
ley are injured. Knowledge of the anatomy and
classification systems of biceps pulley injuries The inferior glenohumeral ligament and the gle-
can assist the clinician to ensure inspecting the nohumeral joint capsule are the most important
appropriate regions during surgery to avoid static stabilizers of the glenohumeral joint [3].
pathology being missed [7, 20]. Choice of treat- The middle and superior glenohumeral ligaments
ment of biceps pulley lesions varies. Some stud- play a more minor role because they are fre-
ies support surgical interventions and repair of quently hypoplastic or congenitally absent [23,
the biceps pulley structures with the goal of 24]. The rotator cuff muscles are the major
restoring the stability of the biceps tendon [21, dynamic stabilizers of the glenohumeral joint
22]. However, biceps tenodesis currently is most which aid in balancing translational (destabiliz-
often performed in these patients [1]. ing) forces with compressive (stabilizing) forces
maintaining glenohumeral joint stability through- and has a prevalence of 2% in the general popula-
out its arc of motion [25–29]. This concavity- tion [45]. The condition affects women more com-
compression mechanism holds the glenohumeral monly than men and tends to occur between 40 and
joint at middle range of motion when the capsu- 60 years of age [45], but it can occur at any age.
lolabral structures are unengaged and at terminal Clinically, affected patients present with shoulder
range of motion when rotator cuff muscle activity pain symptoms which are most pronounced in the
inhibits motion and decreases strain on the gleno- evening, shoulder stiffness lasting >1 month, and
humeral ligaments [30–33]. The biceps tendon absence of other abnormalities explaining the
also plays a key role in maintaining superior sta- symptoms [46]. Spontaneous resolution seems to
bility of the glenohumeral joint [24]. The glenoid occur in almost all patients; however, symptoms
labrum on the other hand acts as a conduit of sta- can persist for approximately 2 years [44]. There is
bility by acting as an anchor site of ligamentous a spectrum and temporal evolution of symptoms
attachment and less significantly by providing with varied clinical presentation and duration that
increased depth to the glenoid fossa [3, 23]. consists of three phases [47]. Phase one is the
Injury to the rotator interval capsule normally “painful freezing phase” where the dominant
results in posterior and inferior glenohumeral joint symptom is pain along with shoulder stiffness last-
instability [34]. Clinically this leads to excessive ing for 10–36 weeks. The second stage is the
inferior translation with the shoulder in adduction “adhesive phase” with near-complete loss of pas-
and external rotation. Harryman et al. [35] demon- sive and active range of motion but gradual pain
strated that resection of the rotator interval capsule subsidence at 4–12 months. The third and final
in cadavers resulted in inferior and posterior trans- stage is the “resolution phase” during which nor-
lation of the adducted shoulder, and subsequent mal range of motion returns to the shoulder sponta-
overlapping redundancy of the rotator interval cap- neously usually seen at 12–42 months.
sule causes increased resistance to inferior and pos- In the literature, adhesive capsulitis is classified
terior translation. The role of the rotator interval into a primary (idiopathic) type with no discover-
capsule to glenohumeral joint stability is believed able inciting event and a secondary type associated
to be that it provides an anatomical negative-pres- with specific injury or an underlying etiology [48].
sure seal to the anterior-superior joint capsule The secondary type is further subcategorized by
between the humeral head and glenoid fossa [20, etiology into the intrinsic type in which rotator
36, 37]. The CHL is also thought to be an important cuff injury or prolonged immobilization (e.g.,
stabilizer providing additional structural support; sports injury) is the inciting event; the extrinsic
however, its role is not as significant as the rotator type associated with a recent abnormality, such as
interval capsule [9]. Ligamentous injury, particu- ipsilateral breast surgery, cervical radiculopathy,
larly the SGHL and CHL, has been shown to result or stroke; and the systemic type in which a sys-
in inferior glenohumeral joint instability [37–39]. temic process triggers the onset as seen with dia-
Furthermore, predisposition to glenohumeral insta- betes, hypothyroidism, and hyperthyroidism.
bility is seen in individuals with developmental The pathophysiologic mechanism in adhesive
defects of the rotator interval [38, 40]. Preferred capsulitis includes a cascade of events that occur
treatment of rotator interval laxity presenting with in the glenohumeral joint capsule, ligaments, and
instability is imbrication of the rotator interval cap- synovium beginning with an initial injury or
sule, performed either arthroscopically or with an underlying systemic disease that leads to thicken-
open approach [40–43]. ing, contraction, and adhesion with decreased
capsular compliance [49, 50]. Studies have
shown immunocytochemical evidence of both
6.3.4 Adhesive Capsulitis proliferative fibroblasts and acute and chronic
inflammatory cells [51–53].
Adhesive capsulitis, also known as frozen shoul- Prompt diagnosis and treatment are critical in
der, was first described in 1934 by Codman [44] adhesive capsulitis because significant delays can
lead to increased patient morbidity [54, 55]. tening of the tendon, particularly at the entrance
Usually conservative treatment with physical to the intertubercular groove, is commonly due to
therapy and intra-articular steroid injection into higher forces on the tendon at this level [12].
the glenohumeral joint is first-line therapy, which Increased MR signal and size of the tendon are
is associated with shortened duration of joint consistent with tendinosis, which is also referred
stiffness [55]. Surgical treatment is performed for to as degeneration (Fig. 6.4) [12, 56, 57].
refractory cases after at least 3–6 months of Disruption and attenuation of a portion of the
appropriate nonoperative treatment. Invasive tendon fibers indicate a partial tendon tear, usu-
therapy consists of manipulation under anesthe- ally longitudinal with split tearing of the tendon
sia to release adhesions or arthroscopic capsular fibers and an appearance of two or more distinct
release [54]. tendon bands (Fig. 6.4). A complete tear mani-
fests as non-visualization of the tendon (Fig. 6.4)
[12]. Subluxation and dislocation manifest as
6.4 Imaging of the Rotator visualization of the LHBT partially or completely
Interval (respectively) outside of the intertubercular
groove (Fig. 6.4). Postoperative changes due to
6.4.1 Imaging of the Biceps Tendon biceps tenotomy again show non-visualization of
the intra-articular LHBT but now has accompa-
Signs of tendon pathology in general throughout nying postoperative changes at the supraglenoid
the body on MR include changes in caliber, con- tubercle where the tendon origin was resected,
tour irregularities, signal intensity abnormalities, which should prompt query for a history of surgi-
partial or complete tears, and subluxation or dis- cal resection (Fig. 6.3). Following biceps tenode-
location [12, 56, 57]. However, evaluation of the sis, the previously mentioned MRI findings are
biceps tendon may be complicated on MRI due to also associated with a fixation device (screw,
its curved course [58], relatively small diameter anchor, or sutures) appearing with a small foci of
[56], normal size variability [59, 60], and magic- magnetic susceptibility artifact at the surgical
angle artifacts of the tendon [56]. reattachment of the distal portion of the resected
Although MR arthrography has inherent biceps tendon stump to the humeral head or the
advantages compared with standard MR imaging proximal humeral shaft in a subpectoral location
in the direct assessment of altered morphology of (Fig. 6.3). Radiographs if available should be
various joints, it has been shown that MR arthrog- correlated because they may show radiodense
raphy does not improve diagnostic accuracy com- metal hardware in the proximal humerus; how-
pared with standard MR imaging when specifically ever, sometimes bioabsorbable screws are used,
analyzing the biceps tendon [12]. In the detection and these will be radiographically occult and a
of biceps tendon pathology of the shoulder, the focal area of osseous rarefaction outlining the
specificities of MR arthrography and computed insertion of the bioabsorbable screw might be the
tomography arthrography are high (94% and only visible finding.
95%, respectively); however, the sensitivities of Entrapment of the LHBT refers to an internal
both are low (27% and 31%, respectively) [57]. impingement at the glenohumeral joint present-
The proximal subacromial intra-articular por- ing with pain and locking of the shoulder on ele-
tion of the LHBT from the biceps anchor to the vation of the arm. Typically this results from
rotator interval is best visualized on sagittal MR severe tendinosis and thickening of the biceps
images [12]. The descending extra-articular por- tendon leading to its impingement [61]. This
tion within the intertubercular groove is better pathology was first described by Boileau et al. in
assessed on axial MR images [12]. The normal a study [62] in which they evaluated 21 patients
biceps tendon is homogeneously hypointense and who on physical examination had tenderness at
round or ovoid on MR imaging with sizes rang- the site of the bicipital groove associated with
ing from 2 to 5 mm [12] (Fig. 6.4); however, flat- loss of passive motion in the final 10–20° of arm
a b
e f
Fig. 6.4 Normal and pathologic appearance of long head onstrates biceps tendinosis or degeneration with increased
of biceps tendon (LHBT) on MRI. (a) Axial fat-saturated signal and thickening of tendon (arrow in c). (d) Axial fat-
T1 MR arthrogram image and (b) sagittal fat-saturated T2 saturated proton density MR images demonstrate a partial
MR image demonstrate normal LHBT (arrows in a and b) tear of the biceps tendon with splitting of the tendon fibers
with normal diameter ranging from 2 to 5 mm and homo- (arrow in d), and (e) complete tear of biceps tendon with
geneous hypointense signal. The normal extra-articular non-visualization of tendon within bicipital groove
LHBT is located within the bicipital groove of humerus (arrow). (f) Axial fat-saturated proton density MR image
and best seen on axial images (a), and intra-articular demonstrates medial dislocation of the biceps tendon
LHBT is located in rotator interval best seen on sagittal (solid arrow) from bicipital groove associated with a com-
images (b). (c) Sagittal T2 fat-saturated MR image dem- plete tear of the subscapularis tendon (dashed arrow)
elevation. On arthrography, every patient had a

a
similar characteristic morphology of the LHBT
related to hypertrophy of the intra-articular
biceps tendon from tendinosis, which they
referred to as the “hourglass biceps.” During
arthroscopic surgery, entrapment of the hypertro-
phic biceps tendon was demonstrated in every
case with dynamic intraoperative maneuvering
they called the “hourglass test,” involving for-
ward elevation of the arm with the elbow
extended. During this test, they noticed a charac-
teristic buckling of the tendon fibers, between the
humeral head and the glenoid osseous margins
creating an hourglass appearance, as it was
pinched in its midportion. They deduced that the
entrapment leads to the hypertrophy of the intra-
articular portion of the tendon, which leads to a
disproportion between the tendon size and the
b
cross-sectional size of the bicipital groove, pre-
venting normal sliding in the bicipital groove,
resulting in entrapment or mechanical blockage.
All cases showed restoration of complete normal
arm elevation, symmetrical to the contralateral
asymptomatic arm, following resection of the
intra-articular portion of the biceps tendon via
either biceps tenodesis or tenotomy. The diagno-
sis of the hourglass biceps is made primarily by
the combination of the appropriate clinical his-
tory and surgical findings described; however,
MRI and MR arthrography may suggest the diag-
nosis when there is this characteristic hypertro-
phic appearance of the intra-articular biceps Fig. 6.5 Hourglass biceps morphology. (a) Sagittal and
tendon with hourglass morphology (Fig. 6.5). (b) coronal fat-saturated T2 MR images demonstrate
severe tendinosis of intra-articular biceps tendon with
marked thickening and increased signal at entry into
bicipital groove resulting in an hourglass morphology
6.4.2 Imaging of the Biceps (arrows), which can be associated with impingement of
Reflection Pulley the tendon
Clinical tests are often equivocal in the diagnosis the supraspinatus tendon (Fig. 6.6) around the
of biceps reflection pulley injury; therefore MRI rotator interval [66], and tears of the superior gle-
is often recommended for the diagnosis in order nohumeral and coracohumeral ligaments
to avoid unnecessary diagnostic arthroscopy [15, (Fig. 6.6) [66].
63, 64]. Diagnostic criteria of biceps pulley Weishaupt el al. [66] demonstrated an overall
injury on MRI include dislocation or medial sub- high sensitivity of 86–93% and a high specificity
luxation of the biceps tendon from the intertuber- of 80–100% in the detection of biceps reflection
cular groove (Figs. 6.4 and 6.6) [16, 20, 65, 66], pulley lesions on MR arthrography using several
tearing of the superior fibers of the subscapularis criteria including tears of the coracohumeral and
tendon (Figs. 6.4 and 6.6) and anterior fibers of superior glenohumeral ligaments, abnormal position
a b
Fig. 6.6 Biceps reflection pulley injuries. (a) Axial fat- (c) coronal fat-saturated proton density MR images dem-
saturated proton density MR image demonstrates medial onstrate medial subluxation and severe tendinosis of
subluxation of biceps tendon from bicipital groove (solid biceps tendon (solid arrow in b, c) associated with a full-
arrow) associated with partial tear of subscapularis tendon thickness tear of anterior supraspinatus tendon insertion
(dashed curved arrow) and partial tear of coracohumeral (dashed arrow in b, c)
ligament insertion (dashed straight arrow). (b) Axial and
and tearing of the biceps tendon, and tears of was located within the intertubercular groove in
superior border of the subscapularis tendon. ~36 of 67 patients (54%) who had a biceps pulley
According to Weishaupt et al. [66], the most tear. Additionally, the arthroscopic incidence of
accurate criterion for the diagnosis of a pulley isolated pulley lesions is substantial, ranging
lesion was an abnormality of the superior border from 29 to 74% [7, 15, 67]. Taking this additional
of the subscapularis tendon. This finding had a arthroscopic data into consideration, Schaeffeler
sensitivity of 86–100% and a specificity of et al. [68] more recently suggested that many pul-
70–80%. ley lesions may be overlooked by following the
However, a more recent arthroscopic study by more traditional MR imaging criteria of biceps
Braun et al. [67] prospectively evaluated 229 tendon location and superior subscapularis integ-
shoulders in consecutive patients who underwent rity because the shoulder is usually examined in
shoulder arthroscopy and found that, with the the neutral position during MR imaging and
shoulder in neutral position, the biceps tendon inference of an intact biceps pulley based on its
anatomical location and/or unremarkable appear- that isolated pulley lesions with a normal
ance of the superior subscapularis tendon can be subscapularis tendon were underrepresented in
inaccurate. the study of Weishaupt et al.
The study by Schaeffeler et al. [68] retrospec- As opposed to Schaeffeler et al., Weishaupt
tively evaluated 80 patients with arthroscopically et al. observed that the tears of the SGHL were
proven intact or torn biceps pulley systems. They specific but insensitive. Schaeffeler et al. pro-
assessed for the presence of a biceps pulley lesion posed that improvements in MR imaging tech-
on MR arthrography using several specific crite- niques over the course of the 10 years between
ria, including medial subluxation of the biceps their two studies and a better understanding of
tendon on transverse images, displacement of the the anatomy may have improved the better visu-
biceps tendon relative to the subscapularis tendon alization of the SGHL in the latter series. The
on oblique sagittal images (displacement sign), study by Schaeffeler et al. included both 1.5-T
presence of biceps tendinopathy, nonvisibility or and 3-T MR studies between 2006 and 2010,
discontinuity of the SGHL, and rotator cuff tears whereas the earlier study by Weishaupt et al. was
adjacent to the rotator interval (supraspinatus and performed on a 1.0-T scanner between 1995 and
subscapularis tendons). They reported high over- 1997, which also supports this assumption. While
all sensitivity of 82–89% and high specificity of review-type articles correlating biceps pulley
87–98% using these criteria, which was concor- lesions on MRI with arthroscopic classification
dant with previous data from Weishaupt et al. have been previously published [1, 61],
[66]. They found that the displacement sign (sen- Schaeffeler et al. [68] note that Bennett’s
sitivity 75–86%, specificity 90–98%), nonvisibil- arthroscopic classification of pulley lesions is
ity or discontinuity of the SGHL (sensitivity specifically not applicable for MR arthrography
75–89%, specificity 75–83%), and tendinopathy because the detailed anatomy at the apex of the
of the biceps tendon (sensitivity 64–93%, speci- rotator interval cannot be visualized on MRI with
ficity 81–96%) were the most accurate measures the same accuracy as arthroscopy.
for the detection of pulley lesions. Subluxation of
the biceps tendon was highly specific (96–100%)
but insensitive (36–64%). Also tears of the sub- 6.4.3 I maging of Rotator Interval
scapularis tendon around the rotator interval were Laxity
highly specific (92–100%) but insensitive (54–
86%). Conversely, tears of the supraspinatus ten- The diagnosis of rotator interval laxity is largely
don around the rotator interval were the least a clinical diagnosis based on history and physical
accurate with low sensitivities (58–87%) and low examination demonstrating posterior and inferior
specificities (61–76%). glenohumeral joint instability. Imaging may play
Studies performed by Weishaupt et al. [66] a supportive role in cases where clinical history
and Scaeffeler et al. [68] had similar overall sen- and examination are inconclusive. MR arthrogra-
sitivities and specificities, but there were some phy is more accurate than conventional non-
significant differences in their results regarding arthrographic MRI because arthrography can
the irregularity of the superior border of the sub- show extra-articular contrast material in the
scapularis tendon, which was highly sensitive for region of the rotator interval typically collecting
pulley lesions in the study by Weishaupt et al. but in the subcoracoid space [69, 70]. This finding
insensitive in the study by Schaeffeler et al. may suggest disruption of the rotator interval
Schaeffeler et al. postulated that their study pop- capsule, particularly if the rotator cuff is intact, in
ulation had a high number of patients with an the appropriate clinical setting.
unremarkable subscapularis tendon (Habermeyer A study by Vinson et al. [71] demonstrated
group I and II lesions) [7], and they suggested intra-articular contrast extending to the cortex
of the undersurface of the coracoid in five on sagittal images; however, coronal and axial
patients with an arthroscopically proven lesion images can occasionally be useful to confirm
of the rotator interval who presented with signs suspected thickening of this ligament. The
of shoulder instability. Tears of the rotator SGHL is often also involved and thickened
interval capsule can also be seen directly on (Fig. 6.7); however, this has not been studied
conventional and/or arthrographic MRI as systematically to the best of our knowledge.
irregularity, thinning, or focal discontinuity of Additional findings frequently associated with
the rotator interval capsule [72]. Patients with adhesive capsulitis on MR imaging included
glenohumeral instability associated with rotator synovial hypertrophy within the rotator interval,
interval laxity may also have increased joint which is seen as replacement of the normal fat
space volume and size in the rotator interval on signal in this region by edema secondary to
MR arthrography [73]. A retrospective study of granulation tissue or scar tissue [77] (Fig. 6.7).
120 shoulders by Kim et al. [73] separated sub- Ultrasound has also demonstrated these findings
jects into groups with and without clinical gle- by showing edema and synovitis with increased
nohumeral instability. Kim et al. measured the vascularity on Doppler imaging of the rotator
size and calculated the volume of the rotator interval [78] (Fig. 6.7). Additionally, thickening
interval using MR arthrography and found sta- and edema of the rotator interval capsule >7 mm
tistically significant differences between the on MR arthrography were shown to have a spec-
two groups, with larger rotator interval dimen- ificity of 86% and sensitivity of 64% by
sions and volumes in those with clinical Mengiardi et al. [77].
instability. Additional changes associated with adhesive
capsulitis outside of the rotator interval can be
seen on MR imaging. A study by Emig et al.
6.4.4 Imaging of Adhesive [50] showed that thickening of the axillary
Capsulitis recess joint capsule and inferior glenohumeral
ligaments >4 mm has a specificity of 95% and
Imaging with MRI or ultrasound has an impor- sensitivity of 70% (Fig. 6.7). Additionally,
tant supportive diagnostic role in the diagnosis of Mengiardi et al. [77] demonstrated a signifi-
adhesive capsulitis because symptoms may be cantly reduced axillary recess volume in patients
misleading and clinical diagnosis can be chal- with adhesive capsulitis on MR arthrography
lenging, particularly in the early stages of disease compared with control subjects (Fig. 6.7).
and when not all of the diagnostic criteria are However, the authors noted that this may not be
met. Furthermore, imaging may also help iden- a true abnormality of adhesive capsulitis but
tify other underlying conditions that can be rather a manifestation of the reduced volume of
masked by the clinical symptoms of adhesive contrast that can be injected in patients with
capsulitis. adhesive capsulitis before there is early leakage
The CHL is considered to be the key struc- of contrast material secondary to weakening in
ture of the rotator interval involved in the patho- the joint capsule. It is also important to note that
logic changes of adhesive capsulitis [2, 74–76] axillary recess volume showed no significant
because this normally flexible structure becomes difference on conventional non-arthrographic
stiff and inelastic resulting in limited external MR imaging between patients with adhesive
rotation [1] (Fig. 6.7). Thickening of the CHL capsulitis and asymptomatic volunteers in a
>4 mm was shown to have a specificity of 95% study by Emig et al. [50]. Thus, this measure-
and a sensitivity of 59% on MR arthrography by ment is not considered to be useful on conven-
Mengiardi et al. [77] (Fig. 6.7). This is best seen tional non-arthrographic MRI.
b c
Fig. 6.7 Adhesive capsulitis. (a) Illustration of involved (arrow). (f) Coronal fat-saturated T2 MR image demon-
structures in adhesive capsulitis highlighted in red indicat- strates thickening and increased signal due to edema in the
ing adhesions and inflammation in rotator interval and axillary recess joint capsule and inferior glenohumeral
thickening and inflammation of joint capsule. (b) Sagittal ligaments (arrow). (g) Coronal fat-saturated T1 MR
T1 and (c) sagittal fat-saturated T2 MR images demon- arthrogram image demonstrates reduced axillary recess
strate thickening and indistinct margin of coracohumeral volume following intra-articular injection of contrast
ligament (CHL) (arrow in b) associated with edematous (arrow). HUM, humeral head; IGHL, inferior glenohu-
effacement of normal surrounding fat signal in rotator meral ligament; LHBT, long head of the biceps tendon;
interval (arrow in c). (d) Transverse ultrasound image of RIC, rotator interval capsule; SGHL, superior glenohu-
the anterior shoulder shows increased vascularity in rota- meral ligament; COR, coracoid. Illustration reprinted
tor interval on power Doppler (red foci) due to edema and with permission from Beltran LS, Beltran J. Biceps and
synovitis. (e) Axial fat-saturated proton density MR image rotator interval: imaging update. Semin Musculoskelet
demonstrates thickening and increased signal of SGHL Radiol. Thieme Medical Publishers; 2014;18:425–35
d e
6.5 Conclusion imaging in assisting the clinician to make the

diagnosis and initiate appropriate treatment.
The rotator interval is a complex anatomical
area containing many important structures that
contribute to the stability and normal function References
of the shoulder joint. We discussed the normal
1. Petchprapa CN, Beltran LS, Jazrawi LM, Kwon
anatomy, clinical and imaging appearances, and
YW, Babb JS, Recht MP. The rotator interval:
treatment options of pathology in the rotator a review of anatomy, function, and normal and
interval and its structures. The complex anat- abnormal MRI appearance. AJR Am J Roentgenol.
omy of the rotator interval within a relatively 2010;195(3):567–76.
2. Neer CS II, Satterlee CC, Dalsey RM, Flatow EL. The
small space makes it challenging to evaluate on
anatomy and potential effects of contracture of the
MR imaging; however, improvements in MR coracohumeral ligament. Clin Orthop Relat Res.
technology as well as a better understanding of 1992;280:182–5.
the anatomy have allowed improved detection 3. Shankman S, Bencardino J, Beltran J. Glenohumeral
instability: evaluation using MR arthrography of the
of disease in this region. Additionally, diagno-
shoulder. Skelet Radiol. 1999;28(7):365–82.
sis of pathology in this area can be clinically 4. Vangsness CT Jr, Jorgenson SS, Watson T, Johnson
challenging, underscoring the important role of DL. The origin of the long head of the biceps from
the scapula and glenoid labrum. An anatomi- 19. Hunt SA, Kwon YW, Zuckerman JD. The rotator
cal study of 100 shoulders. J Bone Joint Surg Br. interval: anatomy, pathology, and strategies for treat-
1994;76(6):951–4. ment. J Am Acad Orthop Surg. 2007;15(4):218–27.
5. Abu-Hijleh MFM. Three-headed biceps brachii 20. Bennett WF. Subscapularis, medial, and lateral
muscle associated with duplicated musculocutaneous head coracohumeral ligament insertion anat-
nerve. Clin Anat. 2005;18(5):376–9. omy. Arthroscopic appearance and incidence of
6. Gaskin CM, Golish SR, Blount KJ, Diduch “hidden” rotator interval lesions. Arthroscopy.
DR. Anomalies of the long head of the biceps bra- 2001;17(2):173–80.
chii tendon: clinical significance, MR arthrographic 21. Stoller DW. Magnetic resonance imaging in ortho-
findings, and arthroscopic correlation in two patients. paedics and sports medicine. Philadelphia: Lippincott
Skelet Radiol. 2007;36(8):785–9. Williams & Wilkins; 2006.
7. Habermeyer P, Magosch P, Pritsch M, Scheibel 22. Bennett WF. Arthroscopic repair of anterosuperior
MT, Lichtenberg S. Anterosuperior impingement (supraspinatus/ subscapularis) rotator cuff tears:
of the shoulder as a result of pulley lesions: a pro- a prospective cohort with 2- to 4- year follow-up.
spective arthroscopic study. J Shoulder Elb Surg. Classification of biceps subluxation/instability.
2004;13(1):5–12. Arthroscopy. 2003;19(1):21–33.
8. Edelson JG, Taitz C, Grishkan A. The coracohumeral 23. O’Connell PW, Nuber GW, Mileski RA,
ligament. Anatomy of a substantial but neglected Lautenschlager E. The contribution of the glenohu-
structure. J Bone Joint Surg Br. 1991;73(1):150–3. meral ligaments to anterior stability of the shoulder
9. Morag Y, Jacobson JA, Shields G, et al. MR arthrog- joint. Am J Sports Med. 1990;18(6):579–84.
raphy of rotator interval, long head of the biceps bra- 24. Warner JJ, McMahon PJ. The role of the long head of
chii, and biceps pulley of the shoulder. Radiology. the biceps brachii in superior stability of the glenohu-
2005;235(1):2130. meral joint. J Bone Joint Surg Am. 1995;77(3):366–72.
10. Burkhead WJ. The biceps tendon. In: Rockwood CJ, 25. Lazarus MD, Sidles JA, Harryman DT II, Matsen FA
Matson FI, editors. The shoulder. Philadelphia: WB III. Effect of a chondral-labral defect on glenoid con-
Saunders; 1990. p. 791–836. cavity and glenohumeral stability. A cadaveric model.
11. Chen C-H, Hsu K-Y, Chen W-J, Shih C-H. Incidence J Bone Joint Surg Am. 1996;78(1):94–102.
and severity of biceps long head tendon lesion in 26. Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA,
patients with complete rotator cuff tears. J Trauma. Harryman DT II, Matsen FA III. Glenohumeral stabil-
2005;58(6):1189–93. ity from concavity-compression: a quantitative analy-
12. Zanetti M, Weishaupt D, Gerber C, Hodler sis. J Shoulder Elb Surg. 1993;2(1):27–35.
J. Tendinopathy and rupture of the tendon of the 27. Lippitt S, Matsen F. Mechanisms of glenohumeral
long head of the biceps brachii muscle: evalua- joint stability. Clin Orthop Relat Res. 1993;291:20–8.
tion with MR arthrography. AJR Am J Roentgenol. 28. Matsen FA III, Harryman DT II, Sidles JA. Mechanics
1998;170(6):1557–61. of glenohumeral instability. Clin Sports Med.
13. Curtis AS, Snyder SJ. Evaluation and treatment of 1991;10(4):783–8.
biceps tendon pathology. Orthop Clin North Am. 29. Porcellini G, Caranzano F, Campi F, Pellegrini A,
1993;24(1):33–43. Paladini P. Glenohumeral instability and rotator cuff
14. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, tear. Sports Med Arthrosc. 2011;19(4):395–400.
Bach BR. Biceps tenotomy versus tenodesis: a review 30. Bigliani LUL, Kelkar R, Flatow ELE, Pollock RGR,
of clinical outcomes and biomechanical results. J Mow VCV. Glenohumeral stability. Biomechanical
Shoulder Elbow Surg. 2011;20(2):326–32. properties of passive and active stabilizers. Clin
15. Baumann B, Genning K, Böhm D, Rolf O, Gohlke Orthop Relat Res. 1996;330:13–30.
F. Arthroscopic prevalence of pulley lesions in 31. Howell SM, Kraft TA. The role of the supraspinatus
1007 consecutive patients. J Shoulder Elb Surg. and infraspinatus muscles in glenohumeral kinemat-
2008;17(1):14–20. ics of anterior should instability. Clin Orthop Relat
16. Walch G, Nové-Josserand L, Boileau P, Levigne Res. 1991;263:128–34.
C. Subluxations and dislocations of the tendon of 32. Lee SB, Kim KJ, O’Driscoll SW, Morrey BF, An
the long head of the biceps. J Shoulder Elb Surg. KN. Dynamic glenohumeral stability provided by the
1998;7(2):100–8. rotator cuff muscles in the mid-range and end-range
17. Gerber C, Sebesta A. Impingement of the deep sur- of motion. A study in cadavera. J Bone Joint Surg Am.
face of the subscapularis tendon and the reflection 2000;82(6):849–57.
pulley on the anterosuperior glenoid rim: a prelimi- 33. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dis-
nary report. J Shoulder Elb Surg. 2000;9(6):483–90. location of the shoulder and rotator cuff rupture. Clin
18. Habermeyer P, Krieter C, Tang K-L, Lichtenberg Orthop Relat Res. 1993;291:103–6.
S, Magosch P. A new arthroscopic classification of 34. Steinbach LS. MRI of shoulder instability. Eur J
articular-sided supraspinatus footprint lesions: a pro- Radiol. 2008;68(1):57–71.
spective comparison with Snyder’s and Ellman’s clas- 35. Harryman DT II, Sidles JA, Harris SL, Matsen FA
sification. J Shoulder Elb Surg. 2008;17(6):909–13. III. The role of the rotator interval capsule in passive
motion and stability of the shoulder. J Bone Joint Surg 54. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med
Am. 1992;74(1):53–66. Arthrosc. 2007;15(4):216–21.
36. Jost B, Koch PP, Gerber C. Anatomy and functional 55. Carette S, Moffet H, Tardif J, et al. Intra-articular cor-
aspects of the rotator interval. J Shoulder Elb Surg. ticosteroids, supervised physiotherapy, or a combina-
2000;9(4):336–41. tion of the two in the treatment of adhesive capsulitis
37. Itoi E, Berglund LJ, Grabowski JJ, Naggar L, Morrey of the shoulder: a placebo-controlled trial. Arthritis
BF, An KN. Superior-inferior stability of the shoulder: Rheum. 2003;48(3):829–38.
role of the coracohumeral ligament and the rotator 56. Buck FM, Grehn H, Hilbe M, Pfirrmann CWA,
interval capsule. Mayo Clin Proc. 1998;73(6):508–15. Manzanell S, Hodler J. Degeneration of the long
38. Burkart AC, Debski RE. Anatomy and function of the biceps tendon: comparison of MRI with gross
glenohumeral ligaments in anterior shoulder instabil- anatomy and histology. AJR Am J Roentgenol.
ity. Clin Orthop Relat Res. 2002;400:32–9. 2009;193(5):1367–75.
39. Warner JJJ, Deng XHX, Warren RFR, Torzilli 57. De Maeseneer M, Boulet C, Pouliart N, et al.
PAP. Static capsuloligamentous restraints to superior- Assessment of the long head of the biceps tendon of
inferior translation of the glenohumeral joint. Am J the shoulder with 3T magnetic resonance arthrography
Sports Med. 1992;20(6):675–85. and CT arthrography. Eur J Radiol. 2012;81(5):934–9.
40. Field LD, Warren RF, O’Brien SJ, Altchek DW, 58. Erickson SJ, Fitzgerald SW, Quinn SF, Carrera
Wickiewicz TL. Isolated closure of rotator interval GF, Black KP, Lawson TL. Long bicipital tendon
defects for shoulder instability. Am J Sports Med. of the shoulder: normal anatomy and pathologic
1995;23(5):557–63. findings on MR imaging. AJR Am J Roentgenol.
41. Karas SG. Arthroscopic rotator interval repair and 1992;158(5):1091–6.
anterior portal closure: an alternative technique. 59. Toshiaki A, Itoi E, Minagawa H, et al. Cross-sectional
Arthroscopy. 2002;18(4):436–9. area of the tendon and the muscle of the biceps bra-
42. Gartsman GMG, Taverna E, Hammerman chii in shoulders with rotator cuff tears: a study of 14
SMS. Arthroscopic rotator interval repair in gleno- cadaveric shoulders. Acta Orthop. 2005;76(4):509–12.
humeral instability: description of an operative tech- 60. Demondion X, Maynou C, Van Cortenbosch B, Klein
nique. Arthroscopy. 1999;15(3):330–2. K, Leroy X, Mestdagh H. Relationship between the
43. Treacy SH, Field LD, Savoie FH. Rotator interval cap- tendon of the long head of the biceps brachii muscle
sule closure: an arthroscopic technique. Arthroscopy. and the glenoid labrum [in French]. Morphologie.
1997;13(1):103–6. 2001;85(269):5–8.
44. Codman EA. Tendinitis of the short rotators. In: 61. Beltran LS, Nikac V, Beltran J. Internal impinge-
Codman EA, editor. Ruptures of the supraspinatus ment syndromes. Magn Reson Imaging Clin N Am.
tendon and other lesions on or about the subacromial 2012;20(2):201–11.. ix–x
bursa. Boston: Thomas Todd Co; 1934. p. 91–9. 62. Boileau P, Ahrens PM, Hatzidakis AM. Entrapment
45. Hannafin JA, Chiaia TA. Adhesive capsulitis. of the long head of the biceps tendon: the hourglass
A treatment approach. Clin Orthop Relat Res. biceps—a cause of pain and locking of the shoulder. J
2000;372:95–109. Shoulder Elb Surg. 2004;13(3):249–57.
46. Manske RC, Prohaska D. Diagnosis and management 63. Bennett WF. Specificity of the Speed’s test:
of adhesive capsulitis. Curr Rev Musculoskelet Med. arthroscopic technique for evaluating the biceps ten-
2008;1(3–4):180–9. don at the level of the bicipital groove. Arthroscopy.
47. Hazleman BL. Frozen shoulder. In: Rockwood CJ, 1998;14(8):789–96.
Matsen FI, editors. The shoulder. 2nd ed. Philadelphia: 64. Chung CB, Dwek JR, Cho GJ, Lektrakul N, Trudell
WB Saunders; 1990. p. 623–77. D, Resnick D. Rotator cuff interval: evaluation
48. Sedeek S, Chye-Andrew TH. Adhesive capsulitis: with MR imaging and MR arthrography of the
is arthroscopic capsular release necessary? Current shoulder in 32 cadavers. J Comput Assist Tomogr.
review. OA Orthopaedics. 2013;1(1):8. 2000;24(5):738–43.
49. Hulstyn MJ, Weiss AP. Adhesive capsulitis of the 65. Walch G, Nove-Josserand L, Levigne C, Renaud
shoulder. Orthop Rev. 1993;22(4):425–33. E. Tears of the supraspinatus tendon associated with
50. Emig EW, Schweitzer ME, Karasick D, Lubowitz “hidden” lesions of the rotator interval. J Shoulder Elb
J. Adhesive capsulitis of the shoulder: MR diagnosis. Surg. 1994;3(6):353–60.
AJR Am J Roentgenol. 1995;164(6):1457–9. 66. Weishaupt D, Zanetti M, Tanner A, Gerber C, Hodler
51. Rodeo SA, Hannafin JA, Tom J, Warren RF, J. Lesions of the reflection pulley of the long biceps
Wickiewicz TL. Immunolocalizationof cytokines and tendon. MR arthrographic findings. Investig Radiol.
their receptors in adhesive capsulitis of the shoulder. J 1999;34(7):463–9.
Orthop Res. 1997;15(3):427–36. 67. Braun S, Horan MP, Elser F, Millett PJ. Lesions of the
52. Simmonds FA. Shoulder pain with particular refer- biceps pulley. Am J Sports Med. 2011;39(4):790–5.
ence to the frozen shoulder. J Bone Joint Surg Br. 68. Schaeffeler C, Waldt S, Holzapfel K, et al. Lesions
1949;31B(3):426–32. of the biceps pulley: diagnostic accuracy of MR
53. Bunker TD, Anthony PP. The pathology of frozen arthrography of the shoulder and evaluation of previ-
shoulder. A Dupuytren-like disease. J Bone Joint Surg ously described and new diagnostic signs. Radiology.
Br. 1995;77(5):677–83. 2012;264(2):504–13.
69. Grainger AJ, Tirman PF, Elliott JM, Kingzett-Taylor 74. Omari A, Bunker TD. Open surgical release for frozen
A, Steinbach LS, Genant HK. MR anatomy of the shoulder: surgical findings and results of the release. J
subcoracoid bursa and the association of subcora- Shoulder Elb Surg. 2001;10(4):353–7.
coid effusion with tears of the anterior rotator cuff 75. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant
and the rotator interval. AJR Am J Roentgenol. chronic adhesive capsulitis of the shoulder. Role of
2000;174(5):1377–80. contracture of the coracohumeral ligament and rotator
70. Le Huec JC, Schaeverbeke T, Moinard M, et al. interval in pathogenesis and treatment. J Bone Joint
Traumatic tear of the rotator interval. J Shoulder Elb Surg Am. 1989;71(10):1511–5.
Surg. 1996;5(1):41–6. 76. Warner JJ, Allen A, Marks PH, Wong P. Arthroscopic
71. Vinson EN, Major NM, Higgins LD. Magnetic release for chronic, refractory adhesive cap-
resonance imaging findings associated with surgi- sulitis of the shoulder. J Bone Joint Surg Am.
cally proven rotator interval lesions. Skelet Radiol. 1996;78(12):1808–16.
2007;36(5):405–10. 77. Mengiardi B, Pfirrmann CWA, Gerber C, Hodler J,
72. Bigoni BJ, Chung CB. MR imaging of the rotator cuff Zanetti M. Frozen shoulder: MR arthrographic find-
interval. Radiol Clin N Am. 2006;44(4):525–36.. viii ings. Radiology. 2004;233(2):486–92.
73. Kim K-C, Rhee K-J, Shin H-D, Kim Y-M. Estimating 78. Lee JC, Sykes C, Saifuddin A, Connell D. Adhesive
the dimensions of the rotator interval with use of mag- capsulitis: sonographic changes in the rotator cuff
netic resonance arthrography. J Bone Joint Surg Am. interval with arthroscopic correlation. Skelet Radiol.
2007;89(11):2450–5. 2005;34(9):522–7.
Part III
The Labrum
Imaging Diagnosis
of Glenohumeral Instability 7
with Clinical Implications
Luis S. Beltran, Monica Tafur,

dislocation include patient age, gender, and ath-

Learning Objectives letic involvement or physical activity [8]. The age
• Discuss the imaging techniques to evaluate of initial dislocation is the most common predis-
the shoulder for glenohumeral instability with posing factor for recurrent dislocation [9–16],
an emphasis on MRI and the rate of recurrent dislocation decreases
• Describe the normal anatomical structures of based on patient age alone [17]. In one study by
the shoulder that pertain to glenohumeral Te Slaa et al., patients younger than 18 years of
stability age had a 71% recurrence rate at 5-year follow-
• Cover the imaging findings and clinical impli- up compared to the overall group of 16–39-year-
cations of glenohumeral instability old patients who demonstrated a recurrence rate
of 55% [16]. Shoulder dislocation is three times
more likely to occur in men compared to women
7.1 Epidemiology [5]. In addition to seeing a higher prevalence of
shoulder dislocation in athletes, other specific
The prevalence of shoulder dislocation is approx- populations in which there is greater physical
imately 1–2% [1–5] in the general population; activity, such as military personnel, also demon-
however recurrent shoulder dislocation can be as strate increased rates of shoulder dislocation
high as 92% in young athletic patients after a compared to the general population [18, 19].
first-time anterior shoulder dislocation which
does not undergo operative treatment [6, 7].
Predictors of recurrent dislocation after an initial 7.2 Imaging Technique
L. S. Beltran (*) Imaging of the shoulder to evaluate for glenohu-

Brigham and Women’s Hospital, Department of meral instability is often first performed with
Radiology, Harvard Medical School, Boston, MA, USA radiography to evaluate the osseous structures for
e-mail: lbeltran@bwh.harvard.edu
glenohumeral joint dislocation and/or fracture.
M. Tafur This includes AP views with the humerus in
Department of Radiology, Michael’s Hospital,
internal and external rotation, scapular Y, and
University of Toronto, Toronto, ON, Canada
axillary views of the affected shoulder.
J. T. Bencardino
Occasionally, additional views are requested by
Langone Health, New York, NY, USA the orthopedic surgeon including a Stryker notch
view to assess for a humeral head fracture and/or
School of Medicine at the University of Pennsylvania, a West Point view to evaluate the anteroinferior
Philadelphia, PA, USA glenoid [8]. If initial radiographic evaluation

demonstrates evidence of bone loss along the diately before the MRI study is performed.
humeral head or glenoid and/or if the patient has Approximately 12–15 mL of contrast material is
a history of multiple prior dislocation events, sufficient to optimally distend the joint. The MRI
then cross-sectional imaging with CT or MRI is sequences may vary from institution to institu-
ordered for further evaluation. tion but typically a coronal oblique fat-saturated
Typically, for a routine shoulder MRI, the T1, coronal oblique fat-saturated T2, sagittal T1,
patient is in the supine position within the MRI axial fat-saturated T1, and oblique axial fat-
scanner and the arm is supinated with the thumb saturated T1 MR sequences with the arm in
facing laterally. To maintain the hand in this posi- abduction and external rotation (ABER) are per-
tion, a sandbag is placed on the hand if the patient formed. To position the shoulder in the ABER
can tolerate this. A phased-array shoulder coil is position, the patient is instructed to place the
placed on the shoulder to optimize signal in the hand of the affected extremity with the palm up
joint; however if the shoulder coil is too small for behind the head of the patient with the elbow
the patient secondary to large body habitus, a flexed. This position produces traction of the
body-phased array coil can be used instead. A typ- anterior-inferior glenohumeral joint capsule over
ical MRI protocol of the shoulder will often the labrum which optimizes evaluation of this
include a combination of fluid-sensitive fat- region for extension of contrast material into the
suppressed images to detect pathology and nonfat- labrum, thereby increasing detection of subtle
suppressed images to evaluate anatomic detail. labral tears [20, 21]. An additional oblique axial
This is often in the form of coronal oblique proton fat-saturated T1 MR arthrogram sequence with
density (PD), coronal oblique fat- saturated T2 the patient in FADIR positioning where the arm
(FST2), sagittal T1, sagittal FST2, and axial fat- in the affected shoulder is flexed, adducted, and
saturated proton density sequences (FSPD). If the internally rotated has improved imaging of the
patient has metal orthopedic hardware, the proto- posterior labrum because of tension/traction of
col can be modified to reduce metal artifact by the posterior capsulolabral structures [22]. This is
increasing the turbo factor and bandwidth, increas- helpful to evaluate for posterior glenohumeral
ing the number of excitations (NEX), and decreas- instability which is much less common than ante-
ing the slice thickness. Additionally, rior instability and thus the FADIR sequence is
frequency- selective fat saturation should be not routinely performed.
avoided and instead short tau inversion recovery
(STIR) sequences should be used to suppress fat
since STIR is less susceptible to metal artifact 7.3 Normal Anatomy
compared to frequency-selective fat saturation
techniques. 7.3.1 Glenohumeral Joint
Injection of contrast material into the gleno-
humeral joint for MR arthrography is usually per- The glenohumeral joint is a ball-and-socket joint
formed to evaluate for abnormal extension of formed by the round articulating surface of the
contrast material into the labrum indicating a humeral head and the concave articular surface of
labral tear which is a frequent finding in glenohu- the glenoid fossa (Fig. 7.1). This configuration
meral instability, and it can also help to evaluate allows the joint to have a wide range of motion
for injury to the joint capsule and rotator cuff. An including adduction, abduction, flexion, exten-
injection of dilute gadolinium contrast is per- sion, internal rotation, external rotation, and 360°
formed into the glenohumeral joint and the circumduction [23]. Although having such a tre-
patient is shortly thereafter placed in the MR mendous range of motion can have the advantage
scanner for imaging. The contrast mixture is pre- of allowing for a wide variety of movements in
pared by mixing 0.1 mL of gadolinium with 20 cc the shoulder, it also comes at a disadvantage of
syringe of normal saline, which can be injected being a very unstable joint and this is the major
under ultrasound or fluoroscopic guidance imme- reason why shoulder instability and shoulder
7 Imaging Diagnosis of Glenohumeral Instability with Clinical Implications 149
a b
c d
e f
Fig. 7.1 Normal anatomy. Axial (a–c), sagittal (d), fat- ligament = thick arrows in (b and d); anterior band of the
saturated MR arthrographic, coronal nonfat-saturated inferior glenohumeral ligament = thick arrow in (c);
T1-weighted (e), and sagittal nonfat-saturated labrum = arrowheads; subscapularis tendon = thin arrows
T2-weighted MR images (f) demonstrating the normal in (b and d); supraspinatus tendon = thick arrow in (e);
MR appearance of the glenohumeral joint stabilizers. Sb = subscapularis muscle; Sp = supraspinatus muscle;
Long head of the biceps tendon = asterisk; superior gleno- In = infraspinatus muscle; Tm = teres minor muscle
humeral ligament = curved arrow; middle glenohumeral
d islocation are very frequent in traumatic injuries mal asymptomatic individuals [27]. With the
such as falls and sports-related injuries [23]. The advancements made in MRI technology in the
instability of the joint is partially alleviated by last decade, a routine MRI study without intra-
multiple reinforcing surrounding structures articular contrast at a high magnetic field strength
which include static stabilizers (glenohumeral of 3 Tesla (3 T) will most likely be adequate to
joint capsule, glenohumeral ligaments, and evaluate for a labral tear because of the high
labrum) and dynamic stabilizers (rotator cuff signal-to-noise ratio and anatomic detail obtained
muscles and tendons, deltoid muscle, and long at 3 T. However, MR arthrography at any field
head of the biceps brachii muscle) working syn- strength (1.5 or 3 T) is still considered the imag-
chronously to maintain the articulation through- ing gold standard to evaluate the labrum [28]
out the ranges of motion required by the because it allows distension of the joint with con-
shoulder. trast material increasing detection of labral tears.
The articular surface of the glenoid fossa is The labrum increases the depth of the glenoid
lined by a thin layer of hyaline cartilage. The gle- fossa by approximately 50% which contributes to
noid normally has a slight retroversion angle of the stability of the glenohumeral joint [27]. The
approximately 7° and has a distinct pear-shaped labrum also provides points of attachment for the
morphology which is best noted on sagittal CT or glenohumeral ligaments, joint capsule, and long
MR images, both of which are essential anatomic head of the biceps tendon (LHBT). The superior
features that help maintain shoulder stability glenohumeral ligament (SGHL) and the LHBT
[24]. The humeral head articular surface is also attach to the superior labrum. The attachment of
covered by a thin layer of hyaline cartilage. The the LHBT to the superior labrum is also referred
rounded morphology of the humeral head partic- to as the biceps labral complex. The middle gle-
ularly along the posterosuperior aspect is also nohumeral ligament (MGHL) attaches to the
essential to maintain the stability of the glenohu- anterior superior labrum. The inferior glenohu-
meral joint. meral ligament (IGHL) complex includes an
anterior band which attaches to the anterior infe-
rior labrum, a posterior band which attaches to
7.4 Labrum and Glenohumeral the posterior inferior labrum, and an intervening
Ligaments axillary pouch which forms the inferior part of
the glenohumeral joint capsule. The labrum has a
The glenoid labrum is composed of fibrocartilage firm attachment along the posterior and inferior
and is attached to the peripheral bony surface of portions of the glenoid rim; however along the
the glenoid rim at the junction of the glenoid superior and anterior superior portions of the gle-
bone and hyaline cartilage articular surfaces, noid rim, the attachment is less firm and can have
referred to as the chondrolabral junction. significant variation in the normal anatomy. If
Normally, the labrum has uniformly low signal one is not familiar with such anatomic variants,
intensity on all MR pulse sequences attributable this can be misinterpreted as a labral tear since
to a short T2 relaxation time because of its these anatomic variants are often associated with
homogenous composition of fibrocartilage. physiologic joint fluid or contrast material exten-
However, there can be normal variations in signal sion around the labrum on MR images, mimick-
intensity including globular and linear increased ing a tear. The major anatomical variants of the
signal, particularly with intermediate-weighted labrum worth noting are [1] the sublabral recess
proton density sequences and in elderly individu- or sublabral sulcus, [2] the sublabral foramen or
als, which is attributed to variations in the com- sublabral hole, and [3] the Buford complex.
position of fibrocartilage [25, 26]. The labrum These anatomic variants of the labrum involve
usually has a triangular shape; however rounded, the anterior half of the labrum which is also a
flat, cleaved, notched morphologies or even common region of the labrum that is injured in
absence of the labrum has been described in nor- anterior glenohumeral instability; therefore a
detailed discussion of these variants is like and thickened (sometimes even frayed
warranted. appearing) MGHL in association with absence of
The sublabral recess (Fig. 7.2), also referred the anterosuperior labrum. This normal variant is
to as a sublabral sulcus, is a normal anatomic present in 1.5–2% of healthy subjects [32] and
potential space between the biceps-labral com- can mimic a tear of the anterosuperior labrum or
plex and the superior aspect of the glenoid rim, MGHL if one is not familiar with this anatomical
which is the result of a synovial reflection at the variant.
insertion of the long head biceps tendon on the
supraglenoid tubercle, and it results in a physio-
logic loose attachment of the superior labrum to 7.4.1 Rotator Cuff
the superior glenoid cartilage [29]. Using the
clock-face analogy to describe the portions of the The muscles of the rotator cuff include the supra-
labrum with 12:00 being located superiorly at the spinatus, infraspinatus, subscapularis, and teres
biceps-labral complex, 3:00 located anteriorly, minor. The supraspinatus muscle has its origin
6:00 located inferiorly, and 9:00 located posteri- along the supraspinatus fossa of the scapula. The
orly, the sublabral recess is located between the infraspinatus muscle origin is at the infraspinatus
11 and 1 o’clock positions in the superior glenoid fossa and the inferior surface of the spine of the
underlying the biceps labral complex. This is best scapula. The teres minor muscle originates at the
appreciated on coronal MRI images, where the lateral border of the scapula. The subscapularis
normal sublabral recess is located at the superior muscle origin is at the subscapularis fossa. The
aspect glenoid rim and points toward the medial rotator cuff muscles approximate each other
side of the glenoid. In contrast, a tear in this along their tendinous insertion sites to the
region of the labrum, which is referred to as supe- humeral head. The subscapularis tendon inserts
rior labrum anteroposterior (SLAP) tear, the tear at the lesser tuberosity of the humeral head and
lesion, points toward the lateral aspect of the the supraspinatus, infraspinatus, and teres minor
superior labrum [30]. tendons insert at the greater tuberosity of the
The sublabral foramen (Fig. 7.2), also referred humeral head. The greater tuberosity is com-
to as a sublabral hole, is a focal physiologic nor- posed of superior, middle, and inferior facets for
mal detachment of the anterosuperior labrum the rotator cuff tendons to insert at. The supraspi-
from the underlying glenoid rim, which is found natus tendon predominantly inserts at the supe-
in approximately 10% of asymptomatic subjects rior facet and the infraspinatus tendon
[31]. When present, it is located between the 1 predominantly inserts at the middle facet, keep-
and 3 o’clock positions of the glenoid, anterior to ing in mind that these two tendons have interdigi-
the biceps labral complex. This normal anatomic tating fibers which fuse and have a partly
variant should not be confused with a tear of the continuous attachment at the margin of the supe-
anterosuperior labrum. Even though they can rior and middle facets [30]. The teres minor ten-
have a similar appearance, there are slight differ- don inserts along the inferior facet. The
ences in morphology which are helpful to differ- subscapularis tendon and supraspinatus tendon
entiate between the normal variant and a also have tendon fibers that interdigitate and fuse
pathologic tear. A normal sublabral foramen is over the bicipital groove between the greater and
only located along the anterior superior labrum, lesser tuberosity, which helps to stabilize the
should not be displaced by more than 1–2 mm, LHBT in its anatomic location within the groove
and should have smooth borders [27]. In contrast, [33].
a labral tear will usually be more prominent and The rotator cuff muscles are the major
have irregular borders and may or may not extend dynamic stabilizers of the glenohumeral joint.
into other portions of the labrum. The supraspinatus muscle abducts the humerus
The Buford complex (Fig. 7.2) is an anatomi- and functions synergistically with the deltoid
cal variant characterized by a prominent or cord- muscle throughout the range of abduction. When
a b
c d
e f
Fig. 7.2 Sublabral recess, sublabral foramen, and Buford (thick arrows). The anterosuperior labrum is detached
complex. (a) Coronal fat-saturated T2-weighted MR from the glenoid with a contrast-filled foramen (thick
image showing a fluid-filled sublabral recess (thick arrow) arrows). Superior and inferior to this foramen, the labrum
between the superior glenoid rim (asterisk) and the (thin arrows) attaches normally to the glenoid. Axial fat-
biceps-labral complex (thin arrow). Axial nonfat-saturated saturated T1-weighted arthrographic MR image (f) show-
T1-weighted (b and c), sagittal fat-saturated T1-weighted ing a Buford complex with a thickened middle
(d), and coronal fat-saturated T2-weighted (e) arthro- glenohumeral ligament (curved arrows) and absence of
graphic MR images demonstrating a sublabral foramen the anterosuperior labrum
supraspinatus function is lost, such as through a dislocated joint among all peripheral joints
tear, there is a substantial increase in the force [36]. Dislocation of the glenohumeral joint is
required from the deltoid muscle to initiate arm most commonly secondary to trauma but can
abduction [34]. The infraspinatus and teres minor also occur in a nontraumatic setting from under-
muscles function to externally rotate the humerus. lying morphologic abnormalities or injuries of
The subscapularis muscle internally rotates and the static and dynamic stabilizing structures of
adducts the humerus. the joint such as the glenoid labrum or rotator
The coupling of the forces of the rotator cuff cuff tendons [37], chronic overuse, and congen-
and deltoid muscles in the coronal and transverse ital laxity [8]. The mechanism of injury in ante-
planes is important for stabilizing the glenohu- rior glenohumeral dislocation involves an
meral joint. When the humerus is abducted and anterior-inferior movement of the humeral head
with overhead movement of the arm, the coupled relative to the glenoid usually caused by a direct
forces of the deltoid muscle and the supraspina- blow to, or fall on, an outstretched arm and typ-
tus muscle are directed toward the glenoid, which ically the patient’s arm is in abduction and
physiologically “compresses” the humeral head external rotation during the traumatic injury.
onto the glenoid and thereby improves the stabil- Patients who suffer from such an initial trau-
ity of the joint by resisting superior humeral head matic dislocation event often have recurrent
displacement [35]. The additional coupling of microtrauma in which minor repetitive injuries
forces between the subscapularis muscle anteri- lead to recurring shoulder dislocations, which
orly and infraspinatus muscle posteriorly also can also lead to injury to the soft-tissue stabiliz-
stabilizes the joint keeping it centered throughout ers [36, 37]. Anterior shoulder dislocation is the
the entire range of motion [35]. most common form of traumatic shoulder insta-
The tendons of the rotator cuff usually have bility, accounting for 90% of all dislocation
low signal on all MR pulse sequences; however, events. Posterior dislocation is much less
there can be focally increased signal in the supra- common, and is typically associated with sei-
spinatus tendon at the distal tendon insertion zure disorders [38].
where the tendon has an oblique course as it
wraps over the greater tuberosity of the humeral
head due to magic angle artifact. Magic angle 7.5.2 Imaging of Glenohumeral
artifact occurs in MR pulse sequences with a rel- Instability
ative short-to-intermediate time to echo (TE)
such as T1 and PD sequences; therefore, one When the clinical suspicion of glenohumeral
should not see it on long TE sequences such as an joint dislocation arises, the initial imaging test
FST2-weighted image. If one is not familiar with that is performed is plain radiography to assess
this common artifact, this can be confused with for dislocation of the glenohumeral joint and any
tendinopathy. possible associated fractures [36]. Cross-
sectional imaging with CT and MRI is often also
performed to further characterize the extent of
7.5 Imaging and Clinical injury and for surgical planning [39]. CT allows
Implications for the most accurate assessment of the osseous
of Glenohumeral Instability injuries associated with shoulder dislocation [40,
41], whereas MRI and MR arthrography is opti-
7.5.1 Mechanism of Injury mal to evaluate the associated soft-tissue injuries
of the labrum, glenohumeral ligaments, and rota-
The wide range of motion of the glenohumeral tor cuff [42]. However, MRI can also provide
joint predisposes it to inherent instability. useful information on the presence and size of
Indeed, it is the most commonly subluxed and osseous injury [43–45].
7.5.3 Capsulolabral Complex A GLAD lesion (Fig. 7.5) represents an ante-

Injuries rior labral tear associated with an adjacent ante-
rior glenoid articular cartilage defect [51]. Unlike
With anterior dislocation, the inferior glenohu- the other mentioned Bankart variants, the GLAD
meral ligament (IGHL) pulls the anterior-inferior lesion is not thought to typically predispose to
margin of the osseous glenoid rim, which results recurrent shoulder dislocation [8].
in an avulsion injury of the labrum and the ante- A HAGL lesion (Fig. 7.6) is another type of
rior band of the inferior glenohumeral ligament, avulsion injury that can occur with anterior
referred to as a soft-tissue Bankart injury [36]. shoulder dislocation and refers to a tear of the
The labrum can become detached off the glenoid humeral attachment of the anterior glenohumeral
at the chondrolabral junction, and often the joint capsule/glenohumeral ligaments [52, 53].
labrum itself is torn and fragmented. When intra- This is a relatively rare lesion that is usually
articular contrast material is injected into the found in the presence of other dislocation-related
joint space during MR arthrography, this can help injuries. A study by Melvin et al. suggests that
establish the diagnosis of a labral tear by demon- MRI may overestimate this type of injury, and
strating contrast extension between the labrum thus definitive diagnosis should be reserved for
and the glenoid indicating detachment. Additional arthroscopy [54]. If there is an osseous avulsion
findings seen with tears of the labrum on conven- fragment of the humeral head attached to a
tional MRI or MR arthrography include abnor- HAGL lesion, this is referred to as a bony HAGL
mal morphology with fraying or fragmentation of or BHAGL.
the labrum, increased signal of the labrum, and
displacement of torn labral tissue.
There are also numerous Bankart injury vari- 7.5.4 Osseous Injuries
ants, which represent a spectrum of different
types of injuries that can occur in the anteroinfe- If there is sufficient force applied to the anterior
rior labrum and capsule with this mechanism of glenoid during an anterior dislocation event, this
injury, including the Perthes lesion, anterior can also lead to fracture of the anteroinferior gle-
labral periosteal sleeve avulsion (ALPSA), and noid with associated bony defect in the glenoid
glenolabral articular disruption (GLAD). rim referred to as a Bankart fracture. Alternatively,
A Perthes lesion (Fig. 7.3) refers to avulsion there can also be flattening of the anterior glenoid
of the anterior labrum at the chondrolabral junc- margin resulting from mechanical erosion or
tion but the labrum remains attached to the gle- impaction from repeated dislocation events [8].
noid because of an intact scapular periosteum The glenoid bone loss that occurs from this injury
[46, 47]. This injury is usually less conspicuous gives the glenoid an inverted pear-shaped mor-
or can even be occult on standard axial MR phology on arthroscopy where the superior aspect
images, typically becoming more apparent when of the glenoid is wider than the inferior portion
the shoulder is in the ABER position [48]. [55]. This is in contrast to its normal appearance
ALPSA lesions (Fig. 7.4) are similar to which resembles a pear with a wider inferior por-
Perthes lesions and can be acute or chronic. An tion and narrower upper portion. With Bankart
acute ALPSA refers to detachment of the anterior fractures, assessment of the morphology and size
labrum at the chondrolabral junction with strip- of the osseous defect of the glenoid bone loss are
ping of the scapular periosteum but the labrum is essential because substantial glenoid bone loss is
non-displaced [49, 50]. A chronic ALPSA associated with surgical failure [27]. Anterior
describes a chronic tear with scarring of the ante- glenohumeral dislocation injuries also often lead
rior labrum which is inferomedially displaced to an impaction fracture deformity of the poste-
along the glenoid neck, but remains attached via rior superior aspect of the humeral head referred
a rim of scapular periosteum [8]. to as a Hill-Sachs fracture. The mechanism of
a b
Fig. 7.3 Perthes lesion. Axial (a) and ABER (abduction tear is best demonstrated on abduction and external
and external rotation) fat-saturated T1-weighted (b) MR rotation as this position stretches the anterior band of
arthrographic images with illustration (c) showing a the inferior glenohumeral ligament (thin arrows),
torn anteroinferior labrum (thick arrows). The labral revealing the lesion
injury is reciprocating impaction that occurs recurrent anterior shoulder instability [58–61]. In
when the anteriorly translated humeral head con- contrast, incorrect underestimation of glenoid
tacts the anteroinferior glenoid rim. Assessment and humeral bone loss and failure to intervene
of the size and morphology of Hill-Sachs frac- and correct such bone loss can lead to a higher
tures is also important because they are associ- risk of recurrent glenohumeral instability [8, 62,
ated with an increased risk of recurrent dislocation 63]. There are several studies supporting the use
after surgical intervention [56, 57]. Furthermore, of 3D reconstructed CT and MR images to accu-
accurate preoperative characterization of com- rately quantify glenoid and humeral bone loss on
bined glenoid and humeral bone loss (referred to [64–69] (Fig. 7.7).
as bipolar bone loss) followed by appropriate Greater tuberosity fractures can also be seen
treatment has been shown to result in favorable in the setting of anterior shoulder dislocation
postoperative outcomes with minimal risk of with a prevalence of 15–35% of patients [70].
a b
c d
e f
Fig. 7.4 Chronic anterior labral periosteal sleeve avul- remains attached to the glenoid by the stripped scapular
sion (ALPSA). Axial (a and b), coronal (c), and ABER periosteum (curved arrow). Note the patulous anterior gle-
fat-saturated T1-weighted (d and e) MR arthrographic nohumeral joint capsule (arrowheads) and associated
images and illustration (f) demonstrating a detached humeral Hill-Sachs lesion (thin arrow). Inferior glenohu-
anteroinferior labrum (thick arrows). There is inferome- meral ligament = arrowheads
dial displacement of the torn labrum (thick arrows), which
a b
Fig. 7.5 Glenolabral articular disruption (GLAD). Axial (thick arrows) with an adjacent defect in the articular car-
(a and b) nonfat-saturated T1-weighted MR arthrographic tilage (thin arrows)
MR images showing a tear or the anteroinferior labrum
a b
Fig. 7.6 Humeral avulsion of the inferior glenohumeral joint fluid (asterisk) into the periarticular tissues. Note the
ligament (HAGL). Coronal (a), sagittal fat-saturated associated intramuscular hematoma in the subscapularis
T2-weighted (b), and axial proton density (PD) MR (curved arrow), tear of the superior labrum or SLAP tear
images (c) demonstrating humeral avulsion of the inferior (thin arrow), and the high-grade tear of the supraspinatus
glenohumeral ligament (thick arrows) with leakage of tendon (arrowhead)
a b
c d
e f
Fig. 7.7 Bankart and Hill-Sachs fractures. Axial (a), sag- arthrographic MR images showing a large osseous
ittal CT reformats (b and c), and 3D reconstruction of the Bankart lesion (thick arrows). The best-fit circle method
glenoid (d) demonstrating Hill-Sachs (arrowheads) and shown on the 3D reconstruction (d) is one of the methods
Bankart fractures (thick arrows). Axial fat-saturated used to quantify the amount of bone loss
T1-weighted (e) and sagittal fat-saturated T2-weighted (f)
Coracoid process fractures associated with gle- arm and associated numbness and paresthesias
nohumeral dislocation are much less common along the lateral surface of the arm. The imaging
[71, 72]. This type of fracture is more often found findings can vary depending on the timing and
in the setting of acromioclavicular separation and extent of injury [86, 87]. In the acute setting, MR
clavicle fracture [73, 74]. imaging may demonstrate no abnormality in the
muscles innervated by the axillary nerve in the
shoulder, which are the teres minor and posterior
7.5.5 Rotator Cuff Injuries deltoid muscles. In the subacute stage of injury,
MRI may show diffuse intramuscular edema
Injuries to the rotator cuff can be associated with within either muscle secondary to denervation
glenohumeral dislocation although they are less injury, particularly if there is no space-occupying
common than the capsulolabral complex and mass in the quadrilateral space to cause direct
osseous Bankart and Hill-Sachs injuries already compression of the nerve [86, 87], and with
discussed [75–82]. These injuries are more com- chronic injury MRI can demonstrate atrophy
mon in elderly patients; however it may be diffi- with fat infiltration in the deltoid and teres minor
cult to differentiate whether this association is muscles [86, 87]. Electrophysiologic studies are
due to preexisting rotator cuff degeneration from often performed to confirm nerve injury and to
age-related factors or related to the dislocation assess for recovery of nerve function [87].
episode itself [8]. The most commonly injured
rotator cuff structure with glenohumeral instabil-
ity is the subscapularis tendon, which is attrib- 7.5.7 Primary Versus Recurrent
uted to its location along the anterior aspect of Dislocation
the joint and its active and passive roles in gleno-
humeral joint stabilization (Fig. 7.8). Gyftopoulos Differentiating between an acute first-time (pri-
et al. [83] demonstrated an association between mary) dislocation event and recurrent dislocation
tendon pathology (tendinosis and tearing) of the can be challenging. The patient’s past medical
middle and inferior subscapularis tendon on MRI history is helpful to differentiate the two; how-
and prior anterior shoulder dislocation, and there- ever this is often not possible as the patient may
fore noted that careful MR assessment of the sub- not be aware of or may fail to mention prior dis-
scapularis tendon is indicated in the setting of locations [8]. In general, various similar types of
anterior shoulder dislocation as injury of this injuries can occur in both patient groups includ-
structure can be symptomatic and may be ame- ing anteroinferior labral pathology, Hill-Sachs
nable to treatment. Tears of the supraspinatus and and glenoid bone loss injuries, and rotator cuff
infraspinatus tendons in association with gleno- tears [88].
humeral instability have also been described in Studies have demonstrated that anterior cap-
elderly patients [8]. sulolabral injuries (soft-tissue Bankart, Perthes,
ALPSA, capsular tears, and capsular laxity) and
osseous Bankart and Hill-Sachs lesions are found
7.5.6 Nerve Injuries in both patients with primary dislocation and
recurrent dislocation, but differ in prevalence [89,
The axillary nerve can be injured with anterior 90]. The presence of an inverted pear morphol-
shoulder dislocation, occurring in a wide range of ogy of the glenoid appears to be the most reliable
5–54% of dislocation patients [84, 85]. Post- indicator of recurrent dislocation [8]. Indeed, this
anterior shoulder dislocation axillary neuropathy appearance of the glenoid has been found to rep-
is attributed to traction on the nerve as it is resent a significant amount of glenoid bone loss
stretched when the humeral head dislocates ante- of at least 25–27% of the inferior glenoid [91].
riorly from the glenoid. Patients typically present Hill-Sachs lesions also tend to be more common
with weakness on elevation and abduction of the in recurrent dislocation [8]. Bankart lesions are
a b
c d
e f
Fig. 7.8 Recurrent anterior glenohumeral dislocation band of the inferior glenohumeral ligament or HAGL lesion
associated with subscapularis tear. Axial nonfat-saturated (thick arrows) with an intact posterior band (arrowhead).
T1-weighted (a–c), coronal fat-saturated T2-weighted (d), There is leakage of intra-articular contrast through the tear
and sagittal fat-saturated T1-weighted (e–f) arthrographic (asterisk). Note the associated Hill-Sachs lesion (curved
MR images demonstrating humeral avulsion of the anterior arrow) and tear of the subscapularis tendon (thin arrows)
seen in high prevalence in both primary and ous defects. In the normal postoperative labrum,
recurrent dislocations [90]. Chronic ALPSA there should be reattachment of the anteroinfe-
lesions are typically associated with recurrent rior labrum and AIGHL to their normal ana-
dislocation, while acute ALPSA lesions are seen tomic position along the anteroinferior glenoid
with primary dislocation. Gyftopoulos et al. [8] on MR arthrography [98]. There can normally
noted that the ALPSA lesion evolves from being be inhomogeneous signal and plump, rounded,
a detached, non-displaced acute tear that over enlarged, or irregular frayed morphology in the
time retracts and scars down to the inferomedial normal postoperative labrum and AIGHL; how-
aspect of the glenoid neck to become a chronic ever these structures should be seen as continu-
lesion and that this scarring and retraction can be, ous intact structures from the labrum to their
in part, related to and escalated by repeated ante- osseous attachments [98]. Findings that indicate
rior shoulder dislocation. recurrent labral tear after Bankart labral repair
on MR arthrography include detachment and
fragmentation of the labrum with extension of
7.5.8 Posterior Instability contrast material into the labrum and/or contrast
separating the labrum from the glenoid
Posterior dislocation injuries of the glenohumeral (Fig. 7.10) [99]. Recurrent tears of the labro-
joint are much less frequent than anterior disloca- ligamentous complex can be partial or complete
tions and are typically associated with seizure separation of the labrum and/or IGHL from the
disorders as the underlying cause of the posterior glenoid [98]. The use of the abduction external
dislocation. Since the forces of injury in posterior rotation (ABER) position on MR arthrography
dislocation are reversed relative to anterior dislo- demonstrating pooling of contrast material
cation injuries, the terms used to describe poste- between the anterior-inferior glenohumeral lig-
rior shoulder dislocation injuries are prefixed ament (AIGHL) and glenoid at the site of surgi-
with the phrase “reverse.” Thus, in a posterior cal reattachment was shown to be a reliable sign
shoulder dislocation, a reverse Hill-Sachs injury of unstable detachment and recurrent labral tear
refers to an impaction fracture of the anterior which was confirmed on arthroscopy [95].
aspect of the humeral head, and a reverse Bankart Additionally, patients who have recurrent dislo-
fracture refers to a fracture of the posterior gle- cation after surgical intervention often also have
noid (Fig. 7.9). Bankart, Perthes, and ALPSA associated signs of acute or worsening osseous
soft-tissue injuries can also be found in posterior Bankart and Hill-Sachs fractures which should
dislocation and have the same imaging character- also be inspected on postoperative
istics, but are found on the posteroinferior aspect MRI. Particularly, osseous signs of recurrent
of the joint and are usually referred to as a reverse anterior shoulder instability in association with
Bankart, reverse Perthes, and/or reverse ALPSA labral re-tear after failed Bankart labral repair
lesions [92]. include bone marrow edema along the anterior
glenoid and posterior humeral head and/or
increased size of glenoid and humeral bone loss
7.5.9 Postoperative Imaging compared to prior imaging if available [99]. It is
also important to assess orthopedic fixation
MR arthrography is the optimal modality to hardware for complications such as hardware
evaluate the integrity of the postoperative fracture, loosening or displacement, and graft
labrum [93–97]. In the postoperative setting fol- nonunion. Other postoperative complications to
lowing treatment of glenohumeral instability, it monitor for on postoperative imaging include
is important to evaluate the integrity of the osteonecrosis, infection, secondary osteoarthri-
repaired structures including the repaired tis, and injury to the adjacent neurovascular
labrum and repairs of glenoid and humeral osse- structures.
a b
c d
Fig. 7.9 Posterior glenohumeral dislocation. Axial fat- saturated T2-weighted MR images demonstrating posterior
saturated T1-weighted MR arthrographic image (a), and subluxation of the glenohumeral joint with a large reverse
axial (b) and sagittal (c) CT reformats showing a reverse osseous Bankart (thick arrow) and Hill-Sachs (arrowhead)
soft-tissue Bankart lesion (thick arrow) and a reverse Hill- fractures. Note the associated intra-articular body (white
Sachs fracture (arrowheads). Axial (d) and sagittal (e) fat- asterisk) and synovitis (black asterisks)
a b
c d
Fig. 7.10 Recurrent postoperative anterior glenohumeral Bankart repair. Axial (c) and sagittal (d) fat-saturated
instability. Preoperative axial nonfat-saturated PD (a) and T1-weighted arthrographic MR images performed 3 years
sagittal fat-saturated T2-weighted MR images (b) demon- after surgery show an enlarging Bankart lesion (white
strating a Hill-Sachs lesion (arrowheads) with bone mar- asterisk) with contrast separating the repaired labrum
row edema (black asterisk) and a small soft-tissue Bankart (thin arrows) from the glenoid (thick arrow) sugges-
lesion (thick arrow) for which the patient underwent tive of a recurrent tear
7.6 Summary involved in glenohumeral instability with an

emphasis on the MRI manifestations.
In summary, it is important to be familiar with the
normal anatomical and pathologic imaging
appearances of the structures in the shoulder to
effectively diagnose and treat glenohumeral
References
instability injuries. This chapter provides an up- 1. Kroner K, Lind T, Jensen J. The epidemiology of
to-date review of the normal shoulder anatomy shoulder dislocations. Arch Orthop Trauma Surg.
and the various clinical and imaging features 1989;108(5):288–90.
2. Nordqvist A, Petersson CJ. Incidence and causes a high-risk population. J Bone Joint Surg Am.
of shoulder girdle injuries in an urban population. J 2009;91(4):791–6.
Shoulder Elbow Surg. 1995;4(2):107–12. 20. Beltran LS, Adler R, Stone T, Surace J, Beltran J,
3. Simonet WT, Melton LJ III, Cofield RH, Ilstrup Bencardino JT. MRI and Ultrasound Imaging of the
DM. Incidence of anterior shoulder dislocation in Shoulder Using Positional Maneuvers. AJR Am J
Olmsted County, Minnesota. Clin Orthop Relat Res. Roentgenol. 2015;205(3):W244–54.
1984;186:186–91. 21. Cvitanic O, Tirman PF, Feller JF, Bost FW, Minter
4. Hovelius L. Shoulder dislocation in Swedish ice J, Carroll KW. Using abduction and external rota-
hockey players. Am J Sports Med. 1978;6(6):373–7. tion of the shoulder to increase the sensitivity of MR
5. Hovelius L. Incidence of shoulder dislocation in arthrography in revealing tears of the anterior glenoid
Sweden. Clin Orthop Relat Res. 1982;166:127–31. labrum. AJR Am J Roentgenol. 1997;169(3):837–44.
6. Arciero RA, Wheeler JH, Ryan JB, McBride 22. Chiavaras MM, Harish S, Burr J. MR arthrographic
JT. Arthroscopic Bankart repair versus nonoperative assessment of suspected posteroinferior labral lesions
treatment for acute, initial anterior shoulder disloca- using flexion, adduction, and internal rotation posi-
tions. Am J Sports Med. 1994;22(5):589–94. tioning of the arm: preliminary experience. Skeletal
7. Wheeler JH, Ryan JB, Arciero RA, Molinari Radiol. 2010;39(5):481–8.
RN. Arthroscopic versus nonoperative treatment 23. Quillen DM, Wuchner M, Hatch RL. Acute shoulder
of acute shoulder dislocations in young athletes. injuries. Am Fam Physician. 2004;70(10):1947–54.
Arthroscopy. 1989;5(3):213–7. 24. Di Giacomo G, Itoi E, Burkhart SS. Evolving con-
8. Gyftopoulos S, Bencardino J, Palmer WE. MR cept of bipolar bone loss and the Hill-Sachs lesion:
imaging of the shoulder: first dislocation versus from "engaging/non-engaging" lesion to "on-track/
chronic instability. Semin Musculoskelet Radiol. off-track" lesion. Arthroscopy. 2014;30(1):90–8.
2012;16(4):286–95. 25. Arai R, Kobayashi M, Toda Y, Nakamura S, Miura T,
9. Hovelius L, Lind B, Thorling J. Primary dislocation Nakamura T. Fiber components of the shoulder supe-
of the shoulder. Factors affecting the two-year prog- rior labrum. Surgical and radiologic anatomy: SRA.
nosis. Clin Orthop Relat Res. 1983;176:181–5. 2012;34(1):49–56.
10. Simonet WT, Cofield RH. Prognosis in anterior shoul- 26. Gustas CN, Tuite MJ. Imaging update on the glenoid
der dislocation. Am J Sports Med. 1984;12(1):19–24. labrum: variants versus tears. Semin Musculoskelet
11. Hovelius L. Anterior dislocation of the shoulder in Radiol. 2014;18(4):365–73.
teen-agers and young adults. Five-year prognosis. J 27. Llopis E, Montesinos P, Guedez MT, Aguilella
Bone Joint Surg Am. 1987;69(3):393–9. L, Cerezal L. Normal Shoulder MRI and MR
12. Vermeiren J, Handelberg F, Casteleyn PP, Opdecam Arthrography: Anatomy and Technique. Semin
P. The rate of recurrence of traumatic anterior disloca- Musculoskelet Radiol. 2015;19(3):212–30.
tion of the shoulder. A study of 154 cases and a review 28. Major NM, Browne J, Domzalski T, Cothran RL,
of the literature. Int Orthop. 1993;17(6):337–41. Helms CA. Evaluation of the glenoid labrum with 3-T
13. Hovelius L, Augustini BG, Fredin H, Johansson O, MRI: is intra-articular contrast necessary? AJR Am J
Norlin R, Thorling J. Primary anterior dislocation of Roentgenol. 2011;196(5):1139–44.
the shoulder in young patients. A ten-year prospective 29. Kwak SM, Brown RR, Resnick D, Trudell D,
study. J Bone Joint Surg Am. 1996;78(11):1677–84. Applegate GR, Haghighi P. Anatomy, anatomic varia-
14. Roberts SN, Taylor DE, Brown JN, Hayes MG, Saies tions, and pathology of the 11- to 3-o'clock position
A. Open and arthroscopic techniques for the treat- of the glenoid labrum: findings on MR arthrogra-
ment of traumatic anterior shoulder instability in phy and anatomic sections. AJR Am J Roentgenol.
Australian rules football players. J Shoulder Elbow 1998;171(1):235–8.
Surg. 1999;8(5):403–9. 30. Rudez J, Zanetti M. Normal anatomy, vari-
15. Kralinger FS, Golser K, Wischatta R, Wambacher ants and pitfalls on shoulder MRI. Eur J Radiol.
M, Sperner G. Predicting recurrence after primary 2008;68(1):25–35.
anterior shoulder dislocation. Am J Sports Med. 31. Stoller DW. MR arthrography of the glenohumeral
2002;30(1):116–20. joint. Radiol Clin North Am. 1997;35(1):97–116.
16. te Slaa RL, Brand R, Marti RK. A prospective 32. Williams MM, Snyder SJ, Buford D Jr. The Buford
arthroscopic study of acute first-time anterior shoul- complex--the "cord-like" middle glenohumeral liga-
der dislocation in the young: a five-year follow-up ment and absent anterosuperior labrum complex: a
study. J Shoulder Elbow Surg. 2003;12(6):529–34. normal anatomic capsulolabral variant. Arthroscopy.
17. Rowe CR. Prognosis in dislocations of the shoulder. J 1994;10(3):241–7.
Bone Joint Surg Am. 1956;38-A(5):957–77. 33. Boon JM, de Beer MA, Botha D, Maritz NG, Fouche
18. Milgrom C, Mann G, Finestone A. A prevalence study AA. The anatomy of the subscapularis tendon inser-
of recurrent shoulder dislocations in young adults. J tion as applied to rotator cuff repair. J Shoulder Elbow
Shoulder Elbow Surg. 1998;7(6):621–4. Surg. 2004;13(2):165–9.
19. Owens BD, Dawson L, Burks R, Cameron 34. Opsha O, Malik A, Baltazar R, Primakov D, Beltran
KL. Incidence of shoulder dislocation in the United S, Miller TT, et al. MRI of the rotator cuff and internal
States military: demographic considerations from derangement. Eur J Radiol. 2008;68(1):36–56.
35. Parsons IM, Apreleva M, Fu FH, Woo SL. The effect 52. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of
of rotator cuff tears on reaction forces at the gleno- glenohumeral ligaments as a cause of anterior shoul-
humeral joint. Journal of orthopaedic research: offi- der instability. Arthroscopy. 1995;11(5):600–7.
cial publication of the Orthopaedic Research Society. 53. Richards DP, Burkhart SS. Arthroscopic humeral
2002;20(3):439–46. avulsion of the glenohumeral ligaments (HAGL)
36. Demehri S, Hafezi-Nejad N, Fishman EK. Advanced repair. Arthroscopy. 2004;20(Suppl 2):134–41.
imaging of glenohumeral instability: the role of MRI 54. Melvin JS, Mackenzie JD, Nacke E, Sennett BJ, Wells
and MDCT in providing what clinicians need to know. L. MRI of HAGL lesions: four arthroscopically con-
Emerg Radiol. 2016;24(1):95–103. firmed cases of false-positive diagnosis. AJR Am J
37. Murray IR, Goudie EB, Petrigliano FA, Robinson Roentgenol. 2008;191(3):730–4.
CM. Functional anatomy and biomechanics of 55. Burkhart SS, De Beer JF. Traumatic glenohumeral
shoulder stability in the athlete. Clin Sports Med. bone defects and their relationship to failure of
2013;32(4):607–24. arthroscopic Bankart repairs: significance of the
38. Shah AS, Karadsheh MS, Sekiya JK. Failure of opera- inverted-pear glenoid and the humeral engaging Hill-
tive treatment for glenohumeral instability: etiology Sachs lesion. Arthroscopy. 2000;16(7):677–94.
and management. Arthroscopy. 2011;27(5):681–94. 56. Mascarenhas R, Rusen J, Saltzman BM, Leiter J,
39. Acid S, Le Corroller T, Aswad R, Pauly V, Champsaur Chahal J, Romeo AA, et al. Management of humeral
P. Preoperative imaging of anterior shoulder instabil- and glenoid bone loss in recurrent glenohumeral insta-
ity: diagnostic effectiveness of MDCT arthrography bility. Advances in orthopedics. 2014;2014:640952.
and comparison with MR arthrography and arthros- 57. Ozaki R, Nakagawa S, Mizuno N, Mae T, Yoneda
copy. AJR Am J Roentgenol. 2012;198(3):661–7. M. Hill-Sachs lesions in shoulders with traumatic
40. Fritz J, Fishman EK, Fayad LM. MDCT Arthrography anterior instability: evaluation using computed
of the Shoulder. Semin Musculoskelet Radiol. tomography with 3-dimensional reconstruction. Am J
2014;18(4):343–51. Sports Med. 2014;42(11):2597–605.
41. Fritz J, Fishman EK, Small KM, Winalski CS, Horger 58. Provencher MT, Bhatia S, Ghodadra NS, Grumet RC,
MS, Corl F, et al. MDCT arthrography of the s houlder Bach BR Jr, Dewing CB, et al. Recurrent shoulder
with datasets of isotropic resolution: indications, instability: current concepts for evaluation and man-
technique, and applications. AJR Am J Roentgenol. agement of glenoid bone loss. J Bone Joint Surg Am.
2012;198(3):635–46. 2010;92(Suppl 2):133–51.
42. Magee T. 3-T MRI of the shoulder: is MR arthrography 59. Piasecki DP, Verma NN, Romeo AA, Levine WN,
necessary? AJR Am J Roentgenol. 2009;192(1):86–92. Bach BR Jr, Provencher MT. Glenoid bone defi-
43. Huijsmans PE, Haen PS, Kidd M, Dhert WJ, van der ciency in recurrent anterior shoulder instability:
Hulst VP, Willems WJ. Quantification of a glenoid diagnosis and management. J Am Acad Orthop Surg.
defect with three-dimensional computed tomography 2009;17(8):482–93.
and magnetic resonance imaging: a cadaveric study. J 60. Warner JJ, Gill TJ, O'Hollerhan JD, Pathare N, Millett
Shoulder Elbow Surg. 2007;16(6):803–9. PJ. Anatomical glenoid reconstruction for recurrent
44. Skendzel JG, Sekiya JK. Diagnosis and management anterior glenohumeral instability with glenoid defi-
of humeral head bone loss in shoulder instability. Am ciency using an autogenous tricortical iliac crest bone
J Sports Med. 2012;40(11):2633–44. graft. Am J Sports Med. 2006;34(2):205–12.
45. Gyftopoulos S, Hasan S, Bencardino J, Mayo J, 61. Provencher MT, Ghodadra N, LeClere L, Solomon
Nayyar S, Babb J, et al. Diagnostic accuracy of MRI DJ, Romeo AA. Anatomic osteochondral glenoid
in the measurement of glenoid bone loss. AJR Am J reconstruction for recurrent glenohumeral instability
Roentgenol. 2012;199(4):873–8. with glenoid deficiency using a distal tibia allograft.
46. Perthes G. Zur therapie der habituellen schulter- Arthroscopy. 2009;25(4):446–52.
luxation. Med Zs. 1905;237:481. 62. Owens BD, DeBerardino TM, Nelson BJ, Thurman J,
47. Perthes G. Ueber operationen bei habitueller schulter- Cameron KL, Taylor DC, et al. Long-term follow-up
luxation. Dtsch Z Chir. 1906;85:199. of acute arthroscopic Bankart repair for initial anterior
48. Wischer TK, Bredella MA, Genant HK, Stoller shoulder dislocations in young athletes. Am J Sports
DW, Bost FW, Tirman PF. Perthes lesion (a variant Med. 2009;37(4):669–73.
of the Bankart lesion): MR imaging and MR arthro- 63. Crall TS, Bishop JA, Guttman D, Kocher M, Bozic K,
graphic findings with surgical correlation. AJR Am J Lubowitz JH. Cost-effectiveness analysis of primary
Roentgenol. 2002;178(1):233–7. arthroscopic stabilization versus nonoperative treat-
49. Neviaser TJ. The anterior labroligamentous periosteal ment for first-time anterior glenohumeral disloca-
sleeve avulsion lesion: a cause of anterior instability tions. Arthroscopy. 2012;28(12):1755–65.
of the shoulder. Arthroscopy. 1993;9(1):17–21. 64. Provencher MT, Frank RM, Leclere LE, Metzger PD,
50. Chung CB, Corrente L, Resnick D. MR arthrography Ryu JJ, Bernhardson A, et al. The Hill-Sachs lesion:
of the shoulder. Magn Reson Imaging Clin N Am. diagnosis, classification, and management. J Am
2004;12(1):25–38.. v-vi Acad Orthop Surg. 2012;20(4):242–52.
51. Neviaser TJ. The GLAD lesion: another cause of 65. Cho SH, Cho NS, Rhee YG. Preoperative analysis of
anterior shoulder pain. Arthroscopy. 1993;9(1):22–3. the Hill-Sachs lesion in anterior shoulder instability:
how to predict engagement of the lesion. Am J Sports injury in the setting of anterior shoulder dislocation.
Med. 2011;39(11):2389–95. Skeletal Radiol. 2012;41(11):1445–52.
66. Stillwater L, Koenig J, Maycher B, Davidson M. 84. Perlmutter GS. Axillary nerve injury. Clin Orthop
3D-MR vs. 3D-CT of the shoulder in patients Relat Res. 1999;368:28–36.
with glenohumeral instability. Skeletal Radiol. 85. Robinson CM, Shur N, Sharpe T, Ray A, Murray
2016;46(3):325–31. IR. Injuries associated with traumatic anterior gle-
67. Gyftopoulos S, Beltran LS, Bookman J, Rokito nohumeral dislocations. J Bone Joint Surg Am.
A. MRI Evaluation of Bipolar Bone Loss Using the 2012;94(1):18–26.
On-Track Off-Track Method: A Feasibility Study. 86. May DA, Disler DG, Jones EA, Balkissoon AA,
AJR Am J Roentgenol. 2015;205(4):848–52. Manaster BJ. Abnormal signal intensity in skeletal
68. Gyftopoulos S, Beltran LS, Yemin A, Strauss E, muscle at MR imaging: patterns, pearls, and pitfalls.
Meislin R, Jazrawi L, et al. Use of 3D MR reconstruc- Radiographics. 2000;20:S295–315.
tions in the evaluation of glenoid bone loss: a clinical 87. Linda DD, Harish S, Stewart BG, Finlay K, Parasu
study. Skeletal Radiol. 2014;43(2):213–8. N, Rebello RP. Multimodality imaging of peripheral
69. Gyftopoulos S, Yemin A, Beltran L, Babb J, neuropathies of the upper limb and brachial plexus.
Bencardino J. Engaging Hill-Sachs lesion: is there an Radiographics. 2010;30(5):1373–400.
association between this lesion and findings on MRI? 88. Hintermann B, Gachter A. Arthroscopic find-
AJR Am J Roentgenol. 2013;201(4):W633–8. ings after shoulder dislocation. Am J Sports Med.
70. McLaughlin HL, MacLellan DI. Recurrent anterior 1995;23(5):545–51.
dislocation of the shoulder. II. A comparative study. J 89. Kim DS, Yoon YS, Yi CH. Prevalence comparison of
Trauma. 1967;7(2):191–201. accompanying lesions between primary and recurrent
71. Goss TP. Fractures of the coracoid process. J Bone anterior dislocation in the shoulder. Am J Sports Med.
Joint Surg Br. 1997;79(4):694. 2010;38(10):2071–6.
72. McGinnis M, Denton JR. Fractures of the scapula: 90. Yiannakopoulos CK, Mataragas E, Antonogiannakis
a retrospective study of 40 fractured scapulae. J E. A comparison of the spectrum of intra-articular
Trauma. 1989;29(11):1488–93. lesions in acute and chronic anterior shoulder insta-
73. Cottalorda J, Allard D, Dutour N, Chavrier Y. Fracture bility. Arthroscopy. 2007;23(9):985–90.
of the coracoid process in an adolescent. Injury. 91. Lo IK, Parten PM, Burkhart SS. The inverted pear
1996;27(6):436–7. glenoid: an indicator of significant glenoid bone loss.
74. Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures Arthroscopy. 2004;20(2):169–74.
of the coracoid process. J Bone Joint Surg Br. 92. Shah N, Tung GA. Imaging signs of posterior gle-
1997;79(1):17–9. nohumeral instability. AJR Am J Roentgenol.
75. Symeonides PP. The significance of the subscapu- 2009;192(3):730–5.
laris muscle in the pathogenesis of recurrent anterior 93. Palmer WE, Caslowitz PL. Anterior shoulder insta-
dislocation of the shoulder. J Bone Joint Surg Br. bility: diagnostic criteria determined from prospec-
1972;54(3):476–83. tive analysis of 121 MR arthrograms. Radiology.
76. Hawkins RJ, Bell RH, Hawkins RH, Koppert 1995;197(3):819–25.
GJ. Anterior dislocation of the shoulder in the older 94. Chandnani VP, Yeager TD, DeBerardino T,
patient. Clin Orthop Relat Res. 1986;206:192–5. Christensen K, Gagliardi JA, Heitz DR, et al. Glenoid
77. Itoi E, Tabata S. Rotator cuff tears in anterior disloca- labral tears: prospective evaluation with MRI imag-
tion of the shoulder. Int Orthop. 1992;16(3):240–4. ing, MR arthrography, and CT arthrography. AJR Am
78. DePalma AF, Cooke AJ, Prabhakar M. The role of the J Roentgenol. 1993;161(6):1229–35.
subscapularis in recurrent anterior dislocations of the 95. Sugimoto H, Suzuki K, Mihara K, Kubota H, Tsutsui
shoulder. Clin Orthop Relat Res. 1967;54:35–49. H. MR arthrography of shoulders after suture-anchor
79. Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent Bankart repair. Radiology. 2002;224(1):105–11.
rupture of the rotator cuff and anterior dislocation of 96. Jana M, Srivastava DN, Sharma R, Gamanagatti S,
the shoulder in the older patient. J Bone Joint Surg Nag HL, Mittal R, et al. Magnetic resonance arthrog-
Am. 1988;70(9):1308–11. raphy for assessing severity of glenohumeral labro-
80. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dis- ligamentous lesions. J Orthop Surg (Hong Kong).
location of the shoulder and rotator cuff rupture. Clin 2012;20(2):230–5.
Orthop Relat Res. 1993;291:103–6. 97. Mutlu S, Mahirogullari M, Guler O, Ucar BY, Mutlu
81. Berbig R, Weishaupt D, Prim J, Shahin O. Primary H, Sonmez G, et al. Anterior Glenohumeral Instability:
anterior shoulder dislocation and rotator cuff tears. J Classification of Pathologies of Anteroinferior
Shoulder Elbow Surg. 1999;8(3):220–5. Labroligamentous Structures Using MR Arthrography.
82. Edouard P, Degache F, Beguin L, Samozino P, Gresta Advances in orthopedics. 2013;2013:473194.
G, Fayolle-Minon I, et al. Rotator cuff strength in 98. Woertler K. Multimodality imaging of the postopera-
recurrent anterior shoulder instability. J Bone Joint tive shoulder. Eur Radiol. 2007;17(12):3038–55.
Surg Am. 2011;93(8):759–65. 99. Beltran LS, Duarte A, Bencardino JT. Postoperative
83. Gyftopoulos S, Carpenter E, Kazam J, Babb J, Imaging in Anterior Glenohumeral Instability. AJR
Bencardino J. MR imaging of subscapularis tendon Am J Roentgenol. 2018;211(3):528–37.
Imaging Diagnosis of SLAP Tears
and Microinstability 8
Konstantin Krepkin, Michael J. Tuite,
8.1 Normal Labrum surface area of the glenoid by approximately one-

third [3, 4]. In conjunction with intra-articular
8.1.1 Anatomy and Biomechanics fluid, the labrum also creates a suction effect on
the humeral head, helping to maintain the
The glenohumeral joint is the most mobile joint in humeral head centered in the glenoid cavity [5].
the body. Static and dynamic stabilizers play a It functions as a bumper-like mechanism to help
vital role in maintaining the stability of the shoul- protect the articular cartilage from compression
der, negotiating the fine balance between physio- and shear damage [1]. Perhaps even more impor-
logic mobility and pathologic laxity. The glenoid tantly, the glenoid labrum allows other glenohu-
labrum is an important static stabilizer of the gle- meral stabilizers to function by providing an
nohumeral joint, consisting of a ring of fibrous attachment site for the glenohumeral ligaments
and fibrocartilaginous tissue along the glenoid and long head of the biceps tendon (LHBT).
rim. The bulk of the labrum consists of dense The glenoid labrum can have a wide range of
fibrous tissue and collagen with a small amount of shapes. A study by Park and colleagues looking at
fibrocartilage at the chondrolabral junction [1, 2]. labral morphology on MR arthrograms in asymp-
The labrum serves to increase the depth and tomatic volunteers found that triangular (64% ante-
surface area of the glenoid fossa, contributing riorly, 47% posteriorly) and round (17% anteriorly,
50% of the glenoid fossa depth and increasing the 33% posteriorly) shapes were the most common
[6]. Flat, cleaved, notched, or absent labral mor-
phologies were also seen. Significant variability
K. Krepkin (*)
also exists in labral size, ranging from 2 to 14 mm
Langone Health, New York, NY, USA in normal individuals [7]. Normally the labrum is
e-mail: konstantin.krepkin@nyumc.org larger at its superior and posterior aspects, com-
M. J. Tuite pared to the inferior and anterior aspects [8]. The
Department of Radiology, University of Wisconsin labrum typically has low signal intensity on all
School of Medicine and Public Health, MRI sequences. However, increased linear or glob-
Madison, WI, USA
e-mail: mtuite@uwhealth.org
ular signal has been described in up to a third of
arthroscopically normal labra [7].
J. T. Bencardino
The glenoid labrum is conventionally divided
Langone Health, New York, NY, USA into four quadrants—anterosuperior, anteroinfe-
rior, posterosuperior, and posteroinferior—by a
School of Medicine at the University of Pennsylvania, horizontal line bisecting the labrum into superior
Philadelphia, PA, USA and inferior halves and a vertical line bisecting

168 K. Krepkin et al.
the labrum into anterior and posterior halves. The

labrum is also commonly divided into a clock
face, with 12 o’clock designating superior and 3
o’clock anterior.
Significant variations exist between the labral
quadrants, both in the incidence of labral pathol-
ogy and normal variants. The posterior and infe-
rior portions of the labrum are most firmly attached
to the glenoid [9, 10]. This helps explain the pre-
ponderance of variants in labral attachment found
in the superior and anterosuperior portions of the
labrum. The superior labrum, and particularly the
anterosuperior quadrant, is the site of attachment Fig. 8.1 Cartilage undercutting. Coronal proton density
of the LHBT and most of the glenohumeral liga- image demonstrates glenoid hyaline cartilage (arrow)
ments. The LHBT attaches at the level of the undercutting the deep portion of the superior labrum
supraglenoid tubercle at approximately the 12 (curved arrow). The cartilage parallels the contour of the
glenoid rim and shows similar intermediate signal inten-
o’clock position. Both the superior (SGHL) and sity to the rest of the glenoid articular cartilage
middle (MGHL) glenohumeral ligaments attach to
the anterosuperior labrum. The anterior band of
the inferior glenohumeral ligament (IGHL) has posterior (SLAP) tear. However, the cartilage has
traditionally been thought to arise from the antero- intermediate signal similar to the rest of the gle-
inferior labrum. However, a recent cadaveric study noid articular cartilage, compared to the high-
by Ramirez Ruiz and colleagues found high origin signal-intensity fluid (on T2-weighted images) or
of the anterior band of the IGHL at or above the 3 gadolinium (on T1-weighted MR arthrogram
o’clock position in four of ten cadaveric shoulders images) insinuating into a labral tear. The carti-
[11]. The intimate relationship between the labrum lage also parallels the contour of the glenoid rim,
and these vital capsular structures partly accounts unlike a SLAP tear, which typically curves later-
for the disproportionate amount of pathology that ally, away from the glenoid [12–14].
occurs in the superior and anterosuperior labrum.
8.1.2.2 Sublabral Recess
The sublabral recess or sulcus is a small cleft
8.1.2 Superior Labral Variants found between the biceps labral complex and the
glenoid cartilage (Fig. 8.2b, c). It is the most
The superior and anterosuperior labrum are com- common anatomic variant of the superior labrum
mon sites for labral anatomic variants. [15], present in up to 73% of shoulders and
These same locations are also common sites for deeper than 2 mm in 39% [16, 17]. Like cartilage
labral pathology, making the distinction between undercutting of the labrum, it can also be con-
pathology and anatomic variant both difficult and fused for a SLAP tear. However, a smooth con-
clinically relevant. Knowledge of the array of ana- tour cleft that parallels the curvature of the
tomic variants that may occur here is crucial to glenoid rim suggests a sublabral recess rather
avoid mistaking them for labral abnormalities. than a SLAP tear [14, 18, 19]. Although initially
thought to never extend posterior to the LHBT
8.1.2.1 Cartilage Undercutting insertion [9], studies have shown that a sublabral
The glenoid hyaline cartilage may sometimes recess can extend posterior to the LHBT insertion
undercut the deep portion of the superior labrum, in the absence of a SLAP tear [17, 20].
creating an extended chondrolabral interface
(Fig. 8.1). This variant has been found in up to 8.1.2.3 Biceps Labral Complex
32% of asymptomatic shoulders [6]. Superficially, Three distinct types of biceps labral complexes
this may resemble a superior labrum anterior- (BLC) have been described (Fig. 8.2) [10]. In
8 Imaging Diagnosis of SLAP Tears and Microinstability 169
a b
Fig. 8.2 Biceps labral complex (BLC). Coronal fat- BLC with the labrum projecting slightly more medially
suppressed T1-weighted MR arthrographic images dem- over the glenoid articular cartilage and a small sublabral
onstrate the three distinct types of biceps labral recess paralleling the contour of the glenoid (arrowhead).
complexes. (a) Type I BLC with firm attachment of the (c) Type III BLC with a meniscoid labrum projecting into
labrum to the underlying glenoid cartilage without carti- the joint space and accompanied by a deep sublabral
lage undercutting or sublabral recess (arrow). (b) Type II recess (arrowhead)
type I BLC, the labrum is firmly attached to the

glenoid without cartilage undercutting or sub-
labral recess present. In type II BLC, the labrum
projects more medially over the glenoid articular
cartilage and there is a small sublabral recess par-
alleling the contour of the glenoid. In type III
BLC, a prominent triangular meniscoid labrum
projects into the joint space and is accompanied
by a deep sublabral recess.
8.1.2.4 Bicipital Labral Sulcus

A shallow cleft can sometimes be found on the
undersurface of the proximal intra-articular
biceps tendon at the junction with the superior
labrum (Fig. 8.3). This bicipital labral sulcus has
been reported to have a prevalence of 30% on
MR arthrography [6].
Fig. 8.3 Bicipital labral sulcus. Coronal fat-suppressed
T1-weighted SPACE image from a direct MR arthrogram
8.1.2.5 Buford Complex demonstrates a shallow cleft on the undersurface of the
An absent or hypoplastic anterosuperior labrum proximal intra-articular biceps tendon at the junction with
accompanied by a thickened cordlike MGHL is the superior labrum (arrow)
a b
Fig. 8.4 Buford complex. (a) Axial fat-suppressed like MGHL (curved arrow). (b) Sagittal T1-weighted image
T1-weighted MR arthrographic images demonstrate an from an MR arthrogram confirms a thickened MGHL
absent anterosuperior labrum (arrow) and a thickened cord- (curved arrow) coursing deep to the subscapularis tendon
known as a Buford complex (Fig. 8.4). This rela-

tively uncommon entity has been reported in
1.5–7.4% of patients [21, 22]. The Buford com-
plex can sometimes be mistaken for a displaced
labral tear. This pitfall can be avoided by follow-
ing the thickened MGHL to its insertion on the
humeral neck or as it blends with the anterior
joint capsule beneath the subscapularis tendon.
Correlating with the sagittal images is also
important since the thickened MGHL can be well
appreciated in the sagittal plane (Fig. 8.4b).
8.1.2.6 Sublabral Foramen

A sublabral foramen is a focal detachment of the
anterosuperior labrum between the 1 o’clock and 3 Fig. 8.5 Sublabral foramen. Axial fat-suppressed proton
o’clock positions (Fig. 8.5) [9]. It can be seen in up density image shows focal detachment of the anterosupe-
rior labrum (arrow). There is a smooth labral contour and
to 18.5% of shoulder arthroscopies and has been lack of significant labral displacement, differentiating the
described in association with a thickened MGHL sublabral foramen from a labral tear
[23]. Although generally thought not to extend
below the level of the midglenoid notch or glenoid smooth labral contour [15]. Interestingly, although
equator, Tuite and colleagues have reported that a a sublabral foramen in and of itself is considered a
sublabral foramen may indeed extend to the normal labral variant, association between sub-
anteroinferior labral quadrant [24]. The features labral foramen and SLAP tears has been found
distinguishing a sublabral foramen from a labral [22, 23, 25]. This may be related to a sublabral
tear include focal detachment of the anterosupe- foramen leading to alterations in biomechanics
rior labrum without involvement of the biceps ori- that produce greater forces on the superior labrum,
gin, labral displacement less than 1–2 mm, and a thus predisposing to labral pathology.
8.2 Microinstability The performance of an elite throwing athlete,

the ability to throw both with high velocity and
8.2.1 Definition accuracy, relies on the complex interplay between
static and dynamic stabilizers of the shoulder.
Microinstability is a heterogeneous set of disor- Furthermore, the entire body is involved in the
ders with complex pathophysiology that presents “kinetic chain” that transmits force from the
a particular challenge both in its clinical and ground up, coordinating the sequence of muscle
imaging evaluation. No universally accepted contractions that culminate in tremendous force
definition exists in the literature. Microinstability generation in the throwing shoulder. Imbalances
is generally understood to consist of poorly in the components of the “kinetic chain” can con-
localized shoulder pain related to pathologic lax- tribute to the deleterious effects on the supporting
ity without frank dislocation [26]. Historically, structures of the shoulder seen in throwing ath-
shoulder instability has been characterized as letes [29, 31–33]. Repetitive distracting forces on
either TUBS (traumatic unidirectional Bankart the throwing shoulder require internal adapta-
lesion, responds to surgery) or AMBRII tions that increase mobility to achieve peak per-
(atraumatic, multidirectional, bilateral, responds formance. At the same time, shoulder stabilizers
to rehabilitation, inferior capsular shift, and are tasked to prevent pathologic laxity and insta-
interval closure) [5, 27]. TUBS typically pres- bility. The fine balance of these competing forces
ents with the classic Bankart and Hill-Sachs on the throwing shoulder is known as the “throw-
lesions seen in anterior shoulder instability, er’s paradox” [34]. The disturbance of this bal-
whereas in AMBRII no obvious structural ance can lead to injury.
lesions are found. Microinstability encompasses
the wide stretch of territory between the two 8.2.2.1 Internal Impingement
extremes of TUBS and AMBRII. It is helpful to There are two main theories that attempt to
subdivide microinstability into two types, one explain the mechanisms of injury and etiology of
associated with repetitive overhead motions— microinstability in the throwing athlete. In the
AIOS (acquired instability in overstressed shoul- anterior laxity internal impingement theory,
der)—and one without—AMSI (atraumatic repetitive abduction and external rotation experi-
minor shoulder instability) [27–30]. enced by the throwing shoulder during the late
cocking and early acceleration phases of the
throwing motion leads to adaptive changes in the
8.2.2 Classification anterior joint capsule. The anterior joint capsule
and Pathophysiology stretches, causing anterior capsular laxity and
leading to anterior instability [35–38]. The lax
AIOS is a common type of microinstability typi- anterior capsule allows for increased external
cally seen in young overhead athletes, such as rotation of the shoulder, which leads to patho-
baseball pitchers, volleyball players, and tennis logic contact between the greater tuberosity, pos-
players. However, individuals whose professions terosuperior labrum, and rotator cuff in a process
require repetitive overhead motions, such as known as internal impingement. Internal
painters and builders, share a similar mechanism impingement typically consists of the triad of
that predisposes them to the development of posterosuperior labral tears, articular surface
microinstability. Much of our knowledge of tearing of the posterior supraspinatus or anterior
microinstability and AIOS is grounded in infraspinatus tendons, and cystic changes in the
research performed to better understand the posterior aspect of the humeral head [39].
mechanics of the throwing athlete. It is this model Posterior humeral head articular cartilage lesions
that we will focus on to help understand the can also be found in the setting of internal
pathophysiology of AIOS. impingement [40].
8.2.2.2 P osterior Capsular Contracture/ corroborated that GIRD has a significant associa-
Glenohumeral Internal tion with pathology in the throwing shoulder. In a
Rotation Deficit study by Verna of 38 overhead athletes with
The alternative theory that attempts to explain the SLAP II tears, all were found to have significant
spectrum of shoulder pathology seen in overhead GIRD, with an average of 33 degrees [44]. A
athletes proposes that the initiating event occurs study by Kibler assigned high-level tennis play-
in the posterior capsule, rather than the anterior ers to two groups, one that performed daily pos-
capsule as suggested by the anterior laxity inter- teroinferior capsular stretching to minimize
nal impingement theory. The posterior capsule GIRD and one that did not [45]. During the
must withstand tensile forces of up to 750 N dur- 2-year follow-up period, the stretching group
ing the deceleration and follow-through phases experienced both a significant increase in internal
of throwing [41]. This repetitive tensile loading rotation and a 38% decrease in the incidence of
on the posteroinferior capsule during the follow- shoulder injury compared to the control group.
through phase eventually causes posteroinferior
capsular hypertrophy and contracture [41, 42]. 8.2.2.3 S uperior Labrum Anterior Cuff
Since the posterior band of the IGHL is located (SLAC) and MGHL Lesions
directly below the humeral head during maxi- There are several types of microinstability not
mum abduction and external rotation seen in the necessarily related to overhead activity. These are
late cocking and early acceleration phases, a con- generally related to injuries to the supporting liga-
tracted posterior band causes posterosuperior mentous structures of the shoulder, in particular
shift of the humeral head relative to the glenoid the superior (SGHL) and middle (MGHL) gleno-
[41, 43]. Such posterosuperior humeral shift humeral ligaments, as well as the rotator interval.
allows for increased humeral external rotation The rotator interval includes the SGHL, coraco-
due to increased clearance of the greater tuberos- humeral ligament, joint capsule, and biceps ten-
ity over the glenoid, but also leads to more pro- don [46]. The SGHL is particularly important in
found internal impingement between the humeral restraining anterior and superior translation of the
head, posterosuperior labrum, and rotator cuff. humeral head in shoulder flexion and lesser
Thus, the ultimate result is the same as proposed degrees of abduction [47–49]. Injury to the SGHL
by the internal impingement theory—pathology can lead to pathologic anterosuperior translation
involving the posterosuperior labrum and adja- of the humeral head with pathologic contact
cent rotator cuff. The posterior capsular contrac- between the humeral head, anterosuperior labrum,
tion theory further suggests that the and rotator cuff. The constellation of anterosupe-
posterosuperior displacement of the humeral rior labral tears, articular surface tearing of the
head causes functional redundancy and slacken- anterior supraspinatus tendon, and SGHL injury
ing of the anteroinferior capsule, producing a is known as the superior labrum anterior cuff
pseudolaxity that may simulate true laxity related (SLAC) lesion [50]. In the original work by
to anterior capsular stretching. Savoie and colleagues, 39 of 40 patients had avul-
Contraction of the posterior capsule also pro- sion of the SGHL, thought to be the inciting event
duces loss of internal rotation in the throwing precipitating a SLAC lesion [50].
shoulder compared to the non-throwing shoulder, The MGHL is the primary anterior stabilizer
a concept known as glenohumeral internal rota- of the shoulder at 45 degrees of abduction and
tion deficit (GIRD). GIRD is defined as a loss of also serves to limit external rotation [27].
internal rotation >18° compared to the contralat- Dysfunction of the MGHL has long been recog-
eral side, which can be easily assessed on physi- nized as a potential cause of microinstability
cal examination [42]. Indeed, research has [51]. In a study by Savoie and colleagues, 33
patients with isolated avulsions of the MGHL rior labral tears, articular surface tears of the
demonstrated evidence of anterior instability posterior supraspinatus or anterior infraspina-
[52]. Subsequent arthroscopic repair led to tus tendons, and cystic changes in the posterior
improvement in pain and function in all patients. aspect of the humeral head (Fig. 8.6) [39, 53].
However, not all findings may necessarily be
8.2.2.4 A traumatic Minor Shoulder present. MR arthrography with ABER (abduc-
Instability (AMSI) tion external rotation) view is optimal for the
A rare form of microinstability not related to over- evaluation of internal impingement since it has
head activity is atraumatic minor shoulder instabil- greater sensitivity for labral pathology and
ity (AMSI). AMSI generally presents as shoulder articular surface rotator cuff tears [53–55]. The
pain after a period of inactivity, such as during ABER view may even depict impingement of
pregnancy or immobilization [27]. These patients the rotator cuff between the greater tuberosity
may have static anatomic variants of the MGHL, and posterosuperior glenoid/labrum since
including absence, hypoplasia, or a large sublabral ABER recreates the abduction and external
foramen or Buford complex [23, 25, 30]. rotation position in which internal impinge-
ment occurs. However, care must be taken not
to misinterpret contact between the undersur-
8.2.3 Imaging Diagnosis face of the rotator cuff and the posterosuperior
of Microinstability glenoid/labrum in the ABER position as inter-
nal impingement in the absence of other associ-
The findings of internal impingement are well ated pathology, since such contact can be seen
depicted on MR imaging. The classic constella- in normal individual placed in the ABER posi-
tion of findings on MRI includes posterosupe- tion [35, 56, 57].
a b
Fig. 8.6 18-Year-old baseball pitcher with shoulder pain. within the posterior aspect of the humeral head (curved
(a) Fat-suppressed T1-weighted abduction external rota- arrow). Findings are consistent with posterosuperior inter-
tion (ABER) view from an MR arthrogram of the shoulder nal impingement. (b) Sagittal T1-weighted image con-
demonstrates tearing of the posterosuperior labrum firms that the cystic changes are present at the anterior
(arrow), articular surface tearing of the posterior supraspi- aspect of the greater tuberosity middle facet (curved
natus tendon fibers (arrowhead), and cystic changes arrow)
a b
Fig. 8.7 21-Year-old baseball pitcher with shoulder pain. intensity adjacent to the posteroinferior aspect of the gle-
(a) Axial gradient-echo and (b) sagittal T1-weighted noid rim (arrow), consistent with mineralization in the set-
images demonstrate a crescent-shaped focus of low signal ting of a Bennett lesion
Several theories exist that attempt to explain rior band of IGHL on MR imaging [59]. A
the occurrence of the posterior humeral head variant of GIRD characterized by a thickened
cysts. Traditionally, they have been thought to be posteroinferior capsule is the Bennett lesion, a
the sequela of impaction injury as the humeral crescent-shaped focus of extra-articular miner-
head abuts the posterosuperior glenoid during the alization at the posteroinferior aspect of the
late cocking and early acceleration phase of glenoid rim from calcification of the posterior
throwing. However, more recently, it has been band of IGHL and adjacent labrum (Fig. 8.7)
proposed that inflammatory changes in the poste- [60, 61].
rior humeral head secondary to internal impinge- Imaging in the classic SLAC lesion reveals
ment may lead to increased vascularity and result tears of the anterosuperior labrum, articular sur-
in cyst formation [39]. face tearing of the anterior supraspinatus tendon,
A number of imaging findings are associ- and injury of the SGHL. However, tears of the
ated with GIRD in the throwing athlete. A cranial fibers of the subscapularis tendon can
study by Tuite and colleagues found that also be seen in the setting of SLAC given their
patients with GIRD have a longer posteroinfe- close proximity to the anterior supraspinatus ten-
rior labrum, thicker posteroinferior capsule, don. SLAC lesions are also associated with
and shallower posterior capsular recess [58]. In lesions of the intra-articular biceps tendon and
a study of professional baseball pitchers with other components of the rotator interval, such as
GIRD, Tehranzadeh and colleagues also the coracohumeral ligament and rotator interval
observed a thickened appearance of the poste- capsule (Fig. 8.8).
a b
Fig. 8.8 60-Year-old male with shoulder pain. (a) Coronal fat-suppressed T2-weighted image demonstrates
Sagittal fat-suppressed T2-weighted image demonstrates a superior labral tear (arrowhead). (c) Sagittal fat-
absence of the biceps tendon, coracohumeral ligament, suppressed T2-weighted image shows an articular surface
and superior glenohumeral ligament (SGHL) in the rota- tear of the far-anterior supraspinatus tendon (curved
tor interval (arrow), consistent with tears. Instead, debris arrow). Constellation of findings can be seen in the setting
and organizing hemorrhage fill the rotator interval. (b) of superior labrum anterior cuff (SLAC) lesion
8.3 SLAP Tears lies in their relationship to the biceps labral com-
plex. As a result, many SLAP tears lead to
8.3.1 Definition and Classification instability of the biceps anchor and result in func-
tional impairment and even microinstability of
Superior labral tears or SLAP (superior labrum the glenohumeral joint.
anterior-posterior) lesions all involve the superior Snyder and colleagues were the first to use the
labrum at the level of the biceps origin, or approx- term SLAP lesion and described the original four
imately the portion of the labrum from 11 o’clock types of SLAP lesions [63]. The classification
to 1 o’clock [62]. The significance of SLAP tears system carries treatment implications, since the
Fig. 8.9 SLAP I lesion.

Coronal fat-suppressed
T2-weighted image
demonstrates
degenerative fraying of
the superior labrum
(arrow), consistent with
a SLAP I lesion
a b
Fig. 8.10 SLAP II lesion. (a) Coronal fat-suppressed fat-suppressed proton density MR arthrographic image at
T2-weighted MR arthrographic image demonstrates the level of the anterosuperior labrum demonstrates that
detachment of the superior labrum and biceps anchor the tear propagates to a sublabral foramen (arrowhead).
from the underlying glenoid with slightly irregular mar- Note that, in contrast to the SLAP tear, the sublabral fora-
gins (arrow), consistent with a SLAP II lesion. (b) Axial men has smooth margins.
different types of SLAP lesions are treated via noid (Fig. 8.10). This results in an unstable
different surgical techniques. Furthermore, the biceps anchor.
different SLAP types have different implications • Type III—Bucket-handle tear of the superior
for the stability of the biceps anchor. The four labrum without extension to the biceps tendon
original types of SLAP tears include: (Fig. 8.11). The central portion of the tear may
or may not be displaced inferiorly into the
• Type I—Degenerative fraying of the superior joint. The biceps anchor remains attached to
labrum with an intact biceps anchor (Fig. 8.9). the glenoid.
• Type II—The superior labrum and biceps • Type IV—Bucket-handle tear of the superior
anchor are detached from the underlying gle- labrum with extension of the tear to the biceps
a b
Fig. 8.11 SLAP III lesion. Coronal (a) and axial (b) fat- the detached labrum surrounded by intra-articular contrast
suppressed T1-weighted MR arthrographic images dem- (arrow). Note a normal biceps tendon (arrowhead)
onstrate a bucket-handle tear of the superior labrum, with
categories have been described [65–67]. Also

tendon. The biceps tendon and the attached
known as extended SLAP, this group of SLAP
labral flap may displace into the joint. This type
lesions encompasses superior labral tears that
of tear renders the biceps anchor unstable.
also propagate to other labral quadrants or capsu-
loligamentous structures (Table 8.1), including a
The passage of synovial fluid through the cleft
superior labral tear propagating to a Bankart
created by a labral tear may result in the forma-
lesion of the anteroinferior labrum (SLAP V)
tion of a paralabral cyst (Fig. 8.12).
(Fig. 8.13), SLAP tear extending to the posterior
There is discrepancy in the frequency of the dif-
labrum (SLAP VIII), circumferential tear of the
ferent SLAP lesions reported in the literature. In
labrum (SLAP IX), and a SLAP lesion that
part, this is related to differences in patient demo-
extends into the rotator interval, including the
graphics across studies, particularly since there is
SGHL, coracohumeral ligament, or rotator inter-
increasing prevalence of degenerative labral fray-
val capsule (SLAP X).
ing with age [64]. However, considerable variabil-
ity also exists in the threshold used by arthroscopists
in classifying the different SLAP lesions. The orig-
inal study by Snyder and colleagues reported the
8.3.2 Pathophysiology
type II SLAP lesion as the most common (41%),
The pathophysiology of SLAP lesions can be
followed by type III (33%), with only 11% of
divided into those that are caused by repetitive
patients having a type I SLAP lesion [63]. However,
overhead activity and those that are not related to
this study looked at a relatively young patient pop-
overhead activity, although there is overlap
ulation, with an average age of 37.5 years, and had
between the two. One of the more common
stringent criteria for classifying type I SLAP
mechanisms for the development of a SLAP
lesions. In a relatively older patient population,
lesion in the non-overhead athlete is a fall on an
with an average age of 44.2 years, Kim and col-
outstretched hand. This mechanism causes com-
leagues found that the type I SLAP lesion was most
pression of the biceps-labral complex between
common, accounting for 74% of SLAP lesions,
the humeral head and glenoid [63]. A biomechan-
followed by type II (21%) [64].
ical study by Clavert and colleagues demon-
In the years following the classification of the
strated that in the setting of a fall on an
original four SLAP lesions, six additional SLAP
a b
Fig. 8.12 SLAP II lesion with paralabral cyst. (a) suppressed T2-weighted and (c) sagittal T1-weighted MR
Coronal fat-suppressed T2-weighted MR arthrographic arthrographic images demonstrate an associated paral-
image demonstrates detachment of the superior labrum abral cyst in the spinoglenoid notch (arrowhead). Note
and biceps anchor from the underlying glenoid (arrow), that the cyst is hypointense on the T1-weighted sequence
consistent with a SLAP II lesion. (b) Coronal fat- since it does not fill with intra-articular contrast
outstretched hand, SLAP tears are more likely tated by inferior subluxation of the humeral head
with a forward fall (shoulder flexed) compared to [69]. In some circumstances, a combination of
a backward fall (shoulder extended) [68]. mechanisms may be responsible for the develop-
Another important mechanism responsible for ment of SLAP lesions in the setting of a single trau-
the pathogenesis of some SLAP lesions is traction matic event. For example, a forceful contraction of
on the biceps-labral complex by forceful contrac- the biceps tendon during a fall on an outstretched
tion of the biceps tendon, such as when lifting a hand can combine both compressive and tensile
heavy object. A biomechanical study by Bey and forces on the superior labrum and biceps anchor.
colleagues found that the generation of SLAP In the overhead-throwing athlete, several fac-
lesions by traction from the biceps tendon is facili- tors contribute to the development of SLAP
lesions. As previously discussed, internal contact between the greater tuberosity, postero-
impingement in the shoulder is caused by exces- superior labrum, and rotator cuff. This mecha-
sive external rotation, which leads to abnormal nism produces posterosuperior SLAP lesions.
Posterior capsular contracture/GIRD also con-
Table 8.1 Classification of SLAP lesions tributes to posterosuperior labral lesions since the
SLAP associated posterosuperior shift of the humeral
lesion Description head relative to the glenoid places increased
Type I Degenerative fraying of the superior labrum stress on the posterosuperior labrum. Finally,
Type II Detachment of the superior labrum and another important component of the cascade of
biceps anchor from the glenoid biomechanical factors resulting in SLAP lesions
Type III Bucket-handle tear of the superior labrum
without extension to the biceps tendon
in the throwing athlete is known as the peel-back
Type IV Bucket-handle tear of the superior labrum mechanism [41, 70]. In the position of maximal
with extension to the biceps tendon shoulder abduction and external rotation experi-
Type V Superior labral tear continuous with a enced during the late cocking and early accelera-
Bankart lesion of the anteroinferior labrum tion phases of throwing, the biceps tendon exerts
Type VI Unstable flap tear of the superior labrum significant tensile and torsional forces on the
Type Superior labral tear that extends anteriorly to
biceps-labral anchor. These forces result in strip-
VII involve the middle glenohumeral ligament
Type Superior labral tear extending to the ping and tearing of the biceps-labral anchor which
VIII posterior labrum (to at least 9 o’clock) may propagate posteriorly, or both posteriorly and
Type IX Circumferential tear of the labrum anteriorly. The combination of the above mecha-
Type X Superior labral tear extending into the nisms results in SLAP lesions in throwing athletes
rotator interval that almost always extend to the posterosuperior
a b
Fig. 8.13 SLAP V lesion. (a) Coronal fat-suppressed inferior labrum (arrow) with stripping of the periosteal
T2-weighted image demonstrates superior labral tear sleeve (arrowhead), consistent with anterior labral perios-
(arrow). Axial fat-suppressed proton density images at the teal sleeve avulsion (ALPSA), a labral Bankart variant.
level of the equator (b) and anteroinferior labrum (c) dem- There is also a Hill-Sachs impaction fracture of the pos-
onstrate propagation of the tear to the anterior and antero- terolateral humeral head (curved arrow)
quadrant. Indeed, SLAP lesions of the anterosu- Indirect MR arthrography involves the intrave-
perior labrum without posterior extension are nous injection of gadolinium-based contrast media
rare in throwing athletes [41]. in a concentration of 0.1 mmol/kg [77]. The intra-
SLAP lesions also contribute to microinstabil- venous contrast diffuses into the joint space over
ity of the shoulder, particularly the lesions that time. The rate of diffusion depends on the perme-
cause instability of the biceps anchor. A study by ability of the joint which is increased in infectious
Pagnani and colleagues found that SLAP lesions and inflammatory conditions, the pressure differ-
that destabilized the biceps anchor resulted in ential between the intravascular and joint spaces,
increased anteroposterior and superoinferior gle- and the viscosity of joint fluid [82, 83]. Exercising
nohumeral translation compared to SLAP lesions the joint prior to imaging increases both vascular
that did not [71]. Hantes and colleagues found a permeability and vascular pressure, thereby
higher rate of preoperative shoulder dislocations in increasing the amount of contrast diffusing into
patients with combined Bankart and SLAP lesions the joint. For the shoulder, imaging is generally
compared to those with Bankart lesions alone [72]. performed with a delay of 15 min after contrast
Indeed, SLAP lesions can be found in both acute injection [83].
and recurrent glenohumeral dislocations [73–75]. For both direct and indirect MR arthrography,
In this setting, SLAP lesions are believed to be the imaging protocol consists of fat-suppressed
contributors to instability rather than the primary T1-weighted sequences in multiple planes to visu-
lesions responsible for instability. alize the contrast material and intra-articular struc-
tures. At least one fluid-sensitive sequence, such as
a STIR, fat-suppressed T2, or fat-suppressed pro-
8.3.3 Technical Considerations: ton density, is also acquired to evaluate for extra-
Conventional MRI Versus MR articular fluid collections, T2 hyperintense
Arthrography periarticular mass lesions, or bone marrow edema.
One of the main advantages of direct MR
MR arthrography is a technique whereby contrast arthrography compared to indirect arthrography
material is introduced into a joint to help visual- or conventional MRI consists of superb joint dis-
ize both normal anatomy and pathology. There tention. This helps separate intra-articular struc-
are two methods to perform MR arthrography— tures, which delineates anatomy and allows
direct and indirect. In direct MR arthrography, contrast to outline defects and tears. The disad-
dilute contrast material is injected directly into a vantages of direct MR arthrography include its
joint via an 18–22 gauge needle [76]. For the relatively invasive nature, which may make some
shoulder, approximately 10–15 mL of a gadolin- patients hesitant to undergo the procedure, and
ium solution is diluted to a concentration of the additional amount of time necessary to per-
1–2 mmol/L with normal saline, lidocaine, and form the intra-articular injection. Although indi-
iodinated contrast if fluoroscopic guidance is rect MR arthrography is not invasive and also
used [76, 77]. Although injection can be done allows contrast to outline intra-articular struc-
without direct visualization, sonographic or fluo- tures, it lacks the capability to create the joint dis-
roscopic guidance is preferred to help insure tention that may be necessary in some cases to
instillation of the contrast mixture into the joint. fully evaluate the joint. Furthermore, since the
Multiple approaches for needle placement can be contrast is not introduced selectively into the
used, including anterior, posterior, and rotator joint of interest with indirect arthrography, other
interval approaches [78–80]. The approach is extra-articular structures can enhance as well,
generally chosen to avoid crossing structures that including blood vessels and synovial lined
are suspected of having pathology. MR imaging spaces, such as bursae and tendon sheaths.
should be performed within 1 h of intra-articular A number of studies have looked at the diag-
injection to maintain adequate contrast-to-noise nostic performance of MR arthrography com-
ratio, as the intra-articular gadolinium diffuses pared to conventional MRI and arthroscopic/
out of the joint with time [81]. surgical findings in diagnosing SLAP lesions. In a
study evaluating direct MR arthrography with sur- field strength systems. The main advantage of 3 T
gical findings as the reference standard, imaging lies in the higher signal-to-noise ratio
Bencardino and colleagues found a high sensitiv- (SNR) afforded by higher field strength systems.
ity (89%), specificity (91%), and accuracy (90%) SNR increases linearly with field strength for fre-
for MR arthrography in diagnosing SLAP lesions quencies less than 250 MHz [92, 93]. This means
[84]. MR arthrography correctly classified 76% of that, with all other parameters held constant, the
SLAP lesions that it identified. A study by Waldt SNR at 3 T is twice that compared to 1.5 T. The
and colleagues found that MR arthrography had extra SNR allows imaging at smaller voxel sizes
sensitivity of 82%, specificity of 98%, and accu- (larger matrix), thus improving spatial resolution,
racy of 94% in diagnosing SLAP lesions [85]. A and has the potential to decrease imaging time,
study by Chandnani and colleagues comparing since the same amount of signal can be acquired
MR arthrography to conventional MR imaging in in a shorter imaging period. As a result, 3 T imag-
the evaluation of labral tears found similar sensi- ing has the potential to afford improved evalua-
tivities, 96% and 93%, respectively [86]. However, tion of small, signal-poor structures, such as the
direct MR arthrography performed better at shoulder labrum, that require both high spatial
detecting detached labral fragments—96% com- resolution and SNR to accurately diagnose tears.
pared to 46% for conventional MRI. Amin and 3 T imaging also allows the implementation of
Youssef found that in 34 patients who had normal a wide array of novel imaging techniques and
conventional MRIs, MR arthrography was able to pulse sequences. Parallel imaging, a technique
detect 18 SLAP lesions that were confirmed by that uses spatial information from individual
arthroscopy [87]. In a study of 20 athletes by radiofrequency coil elements to decrease imag-
Magee and colleagues, MR arthrography detected ing time, can only be performed on high-field-
9 labral tears that were not seen on conventional strength systems, since there is inherent loss of
MRI, 6 of which were SLAP lesions [88]. signal associated with this technique [94]. High-
Comparing indirect MR arthrography to con- field-strength imaging is also necessary to per-
ventional MRI in detecting SLAP lesions, Herold form functional imaging, such as T2 mapping, a
and colleagues found a higher sensitivity (91% vs. technique that has been studied extensively in the
73%), the same specificity (85% vs. 85%), and evaluation of articular cartilage and is gaining
higher accuracy (89% vs. 77%) for indirect MR new applications [95, 96].
arthrography [89]. Dinaeur and colleagues found The multiple advantages of 3 T imaging do
that indirect arthrography had higher sensitivity not come without a cost. The hardware and radio-
(84–91% vs. 66–85%), a slightly higher accuracy frequency coils from a 1.5 T system cannot be
(78–86% vs. 70–83%), but lower specificity (58– simply transposed to a 3 T system; 3 T systems
71% vs. 75–83%) compared to conventional MRI require their own dedicated hardware and coils.
in detecting SLAP lesions [90]. In a head-to-head 3 T imaging accentuates MRI artifacts, alters
comparison of indirect and direct MR arthrogra- image contrast, and presents unique safety chal-
phy, Jung and colleagues found no statistically sig- lenges compared to lower field strength systems.
nificant difference in the sensitivity and specificity Susceptibility artifact, which causes signal loss
of both methods in diagnosing labral tears [91]. and geometric distortion around paramagnetic
materials, such as metal, air, and blood products,
is much more pronounced at 3 T. This artifact is
8.3.4 he Role of Field Strength:
T particularly problematic when imaging orthope-
1.5 T Versus 3 T dic hardware. Chemical shift artifact is also
greater at 3 T due to the doubling of the frequency
With the continued evolution of MR magnets and separation between fat and water [97]. This pro-
coils, 3 T MR imaging is becoming widely avail- duces spatial misregistration at fat-water inter-
able. High-field-strength 3 T MR imaging offers faces that is proportional to the frequency shift
unique benefits and challenges compared to lower between fat and water.
Apart from the exaggeration of artifacts, SLAP lesions, since the majority of labral vari-
another important effect of high-field-strength ants occur in the superior and anterosuperior
imaging is the alteration of T1 contrast due to the labral quadrants. The distinction is important
increase in the T1 relaxation time of tissues [97]. clinically since operating on a normal labral vari-
This leads to loss of signal unless there is com- ant will not address the source of a patient’s pain
pensatory increase in the repetition time (TR). and may lead to adverse consequences. A number
Finally, increased field strength also causes of distinguishing features between variants and
increased energy deposition in the patient, which tears have been proposed, although they are not
can cause tissue heating [94]. This issue can be a always absolute, and correlation with the clinical
particular challenge at 3 T that has required sub- scenario is essential, especially in cases that are
stantial technical advances to overcome and must ambiguous on imaging.
be addressed with each exam by the careful selec- Increased signal can often be seen in the pos-
tion of sequence parameters. Ultimately, the terosuperior labrum in the absence of labral
adjustment of sequence parameters necessary to pathology (Fig. 8.14). This is attributed to magic
overcome significant artifacts, alteration of image angle phenomenon, with the orientation of the
contrast, and problem of increased energy depo- labral collagen fibers in this position relative to
sition may partially offset the increased SNR the main magnetic field generating spurious
afforded by 3 T imaging. increased signal on short TE (echo time)
As far as the evaluation of the diagnostic per- sequences, such as T1 and proton density [105,
formance of 3 T MRI in the detection of SLAP 106]. Adjusting the TE and positioning can help
lesions, Magee and Williams found a sensitivity overcome this artifact (Fig. 8.14) [106].
of 90% and specificity of 100% for conventional Knowledge of this artifact is especially important
3 T MRI compared to arthroscopy [98]. This is as in the context of the overhead-throwing athlete,
good or better than the sensitivity (41–98%) and given the posterosuperior location of labral tears
specificity (75–100%) reported for 1.5 T imaging in posterosuperior internal impingement.
[89, 90, 99–102]. To address whether the advan- The two most common normal variants of the
tages of 3 T imaging may obviate the need for superior labrum include cartilage undercutting
MR arthrography, Magee looked at the diagnos- and sublabral recess. Cartilage undercutting can
tic performance of conventional MRI compared be distinguished from a SLAP tear by its interme-
to MR arthrography at 3 T [103]. MR arthrogra- diate linear signal, similar to the rest of the hya-
phy had a statistically significantly higher sensi- line articular cartilage, that is medially oriented,
tivity (98%) than conventional MRI (83%), with paralleling the contour of the glenoid rim
the same specificity (99%), for the detection of (Fig. 8.1). A SLAP tear, on the other hand, often
SLAP lesions. On the other hand, Major and col- curves laterally away from the glenoid and dem-
leagues showed the same sensitivity (75%) and onstrates irregular margins. Cartilage undercut-
specificity (100%) for MR arthrography and con- ting also demonstrates smooth margins, width
ventional MRI at 3 T in the diagnosis of SLAP less than 2 mm, and normal adjacent labral signal
lesions, although MR arthrography performed [107]. Similarly, a smooth contour fluid signal
better than conventional MRI in the other labral cleft that parallels the curvature of the glenoid
quadrants [104]. and is less than 2 mm in width is highly sugges-
tive of a sublabral recess rather than a SLAP tear
(Fig. 8.2b, c) [108]. The sublabral recess was
8.3.5 I maging Diagnosis of SLAP initially thought to never extend posterior to the
Tears, and Differentiating LHBT insertion [9]. However, given the variabil-
Variants from Tears ity in the superior labral attachment of the LHBT,
studies have shown that a sublabral recess can
The distinction between normal labral variants indeed extend posterior to the LHBT insertion in
and tears is particularly challenging in the case of the absence of a SLAP tear [17, 20, 108].
a b
Fig. 8.14 Magic angle phenomenon in the posterosupe- time), shows a hypointense posterosuperior labrum
rior labrum. (a) Axial and (b) coronal fat-suppressed (arrow), confirming that the increased signal on the
T1-weighted MR arthrographic images demonstrate inter- T1-weighted sequences is an artifact. No posterosuperior
mediate signal in the posterosuperior labrum (arrow). (c) labral injury was found on arthroscopy
Coronal T2-weighted image, which has a longer TE (echo
The variants in the anterosuperior labral quad- ened cordlike MGHL (Fig. 8.4). The Buford
rant that can be confused for a SLAP tear include complex can sometimes be mistaken for a dis-
the sublabral foramen and Buford complex. The placed labral tear. This pitfall can be avoided by
features distinguishing a sublabral foramen from following the thickened MGHL to its insertion on
a SLAP tear include focal detachment of the the humeral neck or as it blends with the anterior
anterosuperior labrum without involvement of joint capsule. Correlating with the sagittal images
the biceps origin, labral displacement less than is also important since the thickened MGHL can
1–2 mm, and a smooth labral contour (Fig. 8.5) be well appreciated in the sagittal plane
[15]. The sublabral foramen is often associated (Fig. 8.4b). Although it was previously thought
with a sublabral recess [109–111]. The Buford that the anterosuperior labral variants cannot
complex represents an absent or a hypoplastic extend below the 3 o’clock position, studies have
anterosuperior labrum accompanied by a thick- shown that both the sublabral foramen and
Buford complex can extend into the anteroinfe- 15. Dunham KS, Bencardino JT, Rokito AS. Anatomic
rior labrum to the level of the anterior band of the variants and pitfalls of the labrum, glenoid cartilage,
and Glenohumeral ligaments. Magn Reson Imaging
IGHL [24, 112]. Clin N Am. 2012;20(2):213–28.
16. Smith DK, Chopp TM, Aufdemorte TB, Witkowski
EG, Jones RC. Sublabral recess of the superior gle-
noid labrum: study of cadavers with conventional
References nonenhanced MR imaging, MR arthrography, ana-
tomic dissection, and limited histologic examina-
1. Nishida K, Hashizume H, Toda K, Inoue tion. Radiology. 1996;201(1):251–6.
H. Histologic and scanning electron microscopic 17. Waldt S, Metz S, Burkart A, Mueller D, Bruegel M,
study of the glenoid labrum. J Shoulder Elb Surg. Rummeny EJ, et al. Variants of the superior labrum
1996;5(2 Pt 1):132–8. and labro-bicipital complex: a comparative study of
2. Huber WP, Putz RV. Periarticular fiber system of shoulder specimens using MR arthrography, multi-
the shoulder joint. Arthrosc J Arthrosc Relat Surg. slice CT arthrography and anatomical dissection.
1997;13(6):680–91. Eur Radiol. 2006;16(2):451–8.
3. Howell SM, Galinat BJ. The glenoid-labral socket. 18. Tuite MJ, Orwin JF. Anterosuperior labral variants
A constrained articular surface. Clin Orthop Relat of the shoulder: appearance on gradient-recalled-
Res. 1989;243:122–5. echo and fast spin-echo MR images. Radiology.
4. Hertz H, Weinstabl R, Grundschober F, Orthner 1996;199(2):537–40.
E. Macroscopic and microscopic anatomy of the 19. Modarresi S, Motamedi D, Jude CM. Superior labral
shoulder joint and the limbus glenoidalis. Acta Anat anteroposterior lesions of the shoulder: part 2, mech-
(Basel). 1986;125(2):96–100. anisms and classification. AJR Am J Roentgenol.
5. Rockwood CA, Matsen FA, editors. The shoulder. 2011;197(3):604–11.
4th ed. Philadelphia, PA: Saunders/Elsevier; 2009. 20. Jin W, Ryu KN, Kwon SH, Rhee YG, Yang
6. Park YH, Lee JY, Moon SH, Mo JH, Yang BK, DM. MR arthrography in the differential diag-
Hahn SH, et al. MR arthrography of the labral cap- nosis of type II superior labral anteroposterior
sular ligamentous complex in the shoulder: imag- lesion and sublabral recess. AJR Am J Roentgenol.
ing variations and pitfalls. AJR Am J Roentgenol. 2006;187(4):887–93.
2000;175(3):667–72. 21. Williams MM, Snyder SJ, Buford D. The Buford
7. Zanetti M, Carstensen T, Weishaupt D, Jost B, Hodler complex--the “cord-like” middle glenohumeral liga-
J. MR arthrographic variability of the arthroscopi- ment and absent anterosuperior labrum complex: a
cally normal glenoid labrum: qualitative and quanti- normal anatomic capsulolabral variant. Arthrosc J
tative assessment. Eur Radiol. 2001;11(4):559–66. Arthrosc Relat Surg. 1994;10(3):241–7.
8. De Maeseneer M, Van Roy P, Shahabpour M. Normal 22. Ilahi OA, Cosculluela PE, Ho DM. Classification
MR imaging anatomy of the rotator cuff tendons, of anterosuperior glenoid labrum variants and their
glenoid fossa, labrum, and ligaments of the shoulder. association with shoulder pathology. Orthopedics.
Radiol Clin N Am. 2006;44(4):479–87.. vii 2008;31(3):226.
9. Cooper DE, Arnoczky SP, O’Brien SJ, Warren RF, 23. Ilahi OA, Labbe MR, Cosculluela P. Variants of
DiCarlo E, Allen AA. Anatomy, histology, and vas- the anterosuperior glenoid labrum and associ-
cularity of the glenoid labrum. An anatomical study. ated pathology. Arthrosc J Arthrosc Relat Surg.
J Bone Joint Surg Am. 1992;74(1):46–52. 2002;18(8):882–6.
10. Stoller DW. Magnetic resonance imaging in 24. Tuite MJ, Blankenbaker DG, Seifert M, Ziegert AJ,
Orthopaedics and sports medicine. 3rd ed. Orwin JF. Sublabral foramen and Buford complex:
Philadelphia, PA: Lippincott Williams & Wilkins; inferior extent of the unattached or absent labrum in
2006. 50 patients. Radiology. 2002;223(1):137–42.
11. Ramirez Ruiz FA, Baranski Kaniak BC, Haghighi 25. Rao AG, Kim TK, Chronopoulos E, McFarland
P, Trudell D, Resnick DL. High origin of the ante- EG. Anatomical variants in the anterosuperior
rior band of the inferior glenohumeral ligament: MR aspect of the glenoid labrum: a statistical analy-
arthrography with anatomic and histologic correla- sis of seventy-three cases. J Bone Joint Surg Am.
tion in cadavers. Skelet Radiol. 2012;41(5):525–30. 2003;85-A(4):653–9.
12. Chloros GD, Haar PJ, Loughran TP, Hayes 26. Wilk KE, Reinold MM, Andrews JR. The Athlete’s
CW. Imaging of glenoid labrum lesions. Clin Sports shoulder. 2nd ed. Philadelphia, PA: Churchill
Med. 2013;32(3):361–90. Livingstone/Elsevier; 2009.
13. Chaipat L, Palmer WE. Shoulder magnetic resonance 27. Castagna A, Nordenson U, Garofalo R, Karlsson
imaging. Clin Sports Med. 2006;25(3):371–86.. v J. Minor shoulder instability. Arthrosc J Arthrosc
14. Lin E. Magnetic resonance arthrography of supe- Relat Surg. 2007;23(2):211–5.
rior labrum anterior-posterior lesions: a practical 28. Silliman JF, Hawkins RJ. Classification and physical
approach to interpretation. Curr Probl Diagn Radiol. diagnosis of instability of the shoulder. Clin Orthop.
2009;38(2):91–7. 1993;291:7–19.
29. Burkhart SS, Morgan CD, Kibler WB. Shoulder 44. Verna C. Shoulder flexibility to reduce impinge-
injuries in overhead athletes. The “dead arm” revis- ment. Im: Presented at the 3rd Annual PBATS
ited. Clin Sports Med. 2000;19(1):125–58. (Professional Baseball Athletic Trainer Society)
30. Steinbeck J, Liljenqvist U, Jerosch J. The anatomy Meeting. Mesa, AZ; 1991.
of the glenohumeral ligamentous complex and its 45. Kibler WB. The relationship of glenohumeral inter-
contribution to anterior shoulder stability. J Shoulder nal rotation deficit to shoulder and elbow injuries
Elb Surg. 1998;7(2):122–6. in tennis players: a prospective evaluation of poste-
31. McQuade KJ, Dawson J, Smidt GL. Scapulothoracic rior capsular stretching. In: Presented at the Annual
muscle fatigue associated with alterations in scapu- closed meeting of the American Shoulder and Elbow
lohumeral rhythm kinematics during maximum Surgeons. New York, NY; 1998.
resistive shoulder elevation. J Orthop Sports Phys 46. Petchprapa CN, Beltran LS, Jazrawi LM, Kwon
Ther. 1998;28(2):74–80. YW, Babb JS, Recht MP. The rotator interval:
32. Paletta GA, Warner JJ, Warren RF, Deutsch A, a review of anatomy, function, and normal and
Altchek DW. Shoulder kinematics with two-plane abnormal MRI appearance. AJR Am J Roentgenol.
x-ray evaluation in patients with anterior insta- 2010;195(3):567–76.
bility or rotator cuff tearing. J Shoulder Elb Surg. 47. Chang EY, Fliszar E, Chung CB. Superior
1997;6(6):516–27. labrum anterior and posterior lesions and micro-
33. Warner JJ, Micheli LJ, Arslanian LE, Kennedy instability. Magn Reson Imaging Clin N Am.
J, Kennedy R. Scapulothoracic motion in normal 2012;20(2):277–94.
shoulders and shoulders with glenohumeral insta- 48. Bowen MK, Warren RF. Ligamentous control of
bility and impingement syndrome. A study using shoulder stability based on selective cutting and
Moiré topographic analysis. Clin Orthop Relat Res. static translation experiments. Clin Sports Med.
1992;285:191–9. 1991;10(4):757–82.
34. Wilk KE, Arrigo C. Current concepts in the rehabili- 49. Speer KP. Anatomy and pathomechanics of shoulder
tation of the athletic shoulder. J Orthop Sports Phys instability. Clin Sports Med. 1995;14(4):751–60.
Ther. 1993;18(1):365–78. 50. Savoie FH, Field LD, Atchinson S. Anterior superior
35. Walch G, Boileau P, Noel E, Donell ST. Impingement instability with rotator cuff tearing: SLAC lesion.
of the deep surface of the supraspinatus tendon on Orthop Clin North Am. 2001;32(3):457–61.. ix
the posterosuperior glenoid rim: an arthroscopic 51. Townley CO. The capsular mechanism in recurrent
study. J Shoulder Elb Surg. 1992;1(5):238–45. dislocation of the shoulder. J Bone Joint Surg Am.
36. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain 1950;32A(2):370–80.
in the overhand or throwing athlete. The relationship 52. Savoie FH, Papendik L, Field LD, Jobe C. Straight
of anterior instability and rotator cuff impingement. anterior instability: lesions of the middle glenohu-
Orthop Rev. 1989;18(9):963–75. meral ligament. Arthrosc J Arthrosc Relat Surg.
37. Jobe CM. Posterior superior glenoid impingement: 2001;17(3):229–35.
expanded spectrum. Arthrosc J Arthrosc Relat Surg. 53. Tirman PF, Bost FW, Garvin GJ, Peterfy CG, Mall
1995;11(5):530–6. JC, Steinbach LS, et al. Posterosuperior glenoid
38. Chung CB, Steinbach LS. MRI of the upper extrem- impingement of the shoulder: findings at MR imag-
ity: shoulder, elbow, wrist and hand. Philadelphia, ing and MR arthrography with arthroscopic correla-
PA: Lippincott Williams & Wilkins; 2009. tion. Radiology. 1994;193(2):431–6.
39. Giaroli EL, Major NM, Higgins LD. MRI of internal 54. Flannigan B, Kursunoglu-Brahme S, Snyder S,
impingement of the shoulder. AJR Am J Roentgenol. Karzel R, Del Pizzo W, Resnick D. MR arthrog-
2005;185(4):925–9. raphy of the shoulder: comparison with con-
40. Kaplan LD, McMahon PJ, Towers J, Irrgang JJ, ventional MR imaging. AJR Am J Roentgenol.
Rodosky MW. Internal impingement: findings 1990;155(4):829–32.
on magnetic resonance imaging and arthroscopic 55. Palmer WE, Brown JH, Rosenthal DI. Rotator cuff:
evaluation. Arthrosc J Arthrosc Relat Surg. evaluation with fat-suppressed MR arthrography.
2004;20(7):701–4. Radiology. 1993;188(3):683–7.
41. Burkhart SS, Morgan CD, Kibler WB. The dis- 56. Barber FA, Morgan CD, Burkhart SS, Jobe
abled throwing shoulder: spectrum of pathology CM. Current controversies. Point counterpoint.
part I: pathoanatomy and biomechanics. Arthrosc J Labrum/biceps/cuff dysfunction in the throw-
Arthrosc Relat Surg. 2003;19(4):404–20. ing athlete. Arthrosc J Arthrosc Relat Surg.
42. Kibler WB, Kuhn JE, Wilk K, Sciascia A, Moore S, 1999;15(8):852–7.
Laudner K, et al. The disabled throwing shoulder: 57. Gold GE, Pappas GP, Blemker SS, Whalen ST,
spectrum of pathology-10-year update. Arthrosc J Campbell G, McAdams TA, et al. Abduction and
Arthrosc Relat Surg. 2013;29(1):141–61. external rotation in shoulder impingement: an open
43. Grossman MG, Tibone JE, McGarry MH, Schneider MR study on healthy volunteers initial experience.
DJ, Veneziani S, Lee TQ. A cadaveric model of the Radiology. 2007;244(3):815–22.
throwing shoulder: a possible etiology of superior 58. Tuite MJ, Petersen BD, Wise SM, Fine JP, Kaplan
labrum anterior-to-posterior lesions. J Bone Joint LD, Orwin JF. Shoulder MR arthrography of the pos-
Surg Am. 2005;87(4):824–31. terior labrocapsular complex in overhead throwers
with pathologic internal impingement and internal 73. Taylor DC, Arciero RA. Pathologic changes asso-
rotation deficit. Skelet Radiol. 2007;36(6):495–502. ciated with shoulder dislocations. Arthroscopic
59. Tehranzadeh AD, Fronek J, Resnick D. Posterior and physical examination findings in first-time,
capsular fibrosis in professional baseball pitch- traumatic anterior dislocations. Am J Sports Med.
ers: case series of MR arthrographic findings in six 1997;25(3):306–11.
patients with glenohumeral internal rotational defi- 74. Yiannakopoulos CK, Mataragas E, Antonogiannakis
cit. Clin Imaging. 2007;31(5):343–8. E. A comparison of the spectrum of intra-articular
60. Bennett GE. Elbow and shoulder lesions of baseball lesions in acute and chronic anterior shoul-
players. Am J Surg. 1959;98:484–92. der instability. Arthrosc J Arthrosc Relat Surg.
61. De Maeseneer M, Jaovisidha S, Jacobson JA, 2007;23(9):985–90.
Tam W, Schils JP, Sartoris DJ, et al. The Bennett 75. Antonio GE, Griffith JF, Yu AB, Yung PSH, Chan
lesion of the shoulder. J Comput Assist Tomogr. KM, Ahuja AT. First-time shoulder dislocation: high
1998;22(1):31–4. prevalence of labral injury and age-related differ-
62. Andrews JR, Carson WG, McLeod WD. Glenoid ences revealed by MR arthrography. J Magn Reson
labrum tears related to the long head of the biceps. Imaging. 2007;26(4):983–91.
Am J Sports Med. 1985;13(5):337–41. 76. Sebro R, Oliveira A, Palmer WE. MR arthrogra-
63. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, phy of the shoulder: technical update and clini-
Friedman MJ. SLAP lesions of the shoulder. cal applications. Semin Musculoskelet Radiol.
Arthrosc J Arthrosc Relat Surg. 1990;6(4):274–9. 2014;18(4):352–64.
64. Kim TK, Queale WS, Cosgarea AJ, McFarland 77. La Rocca VR, Rybak LD, Recht M. Technical
EG. Clinical features of the different types of SLAP update on magnetic resonance imaging of the
lesions: an analysis of one hundred and thirty-nine shoulder. Magn Reson Imaging Clin N Am.
cases. J Bone Joint Surg Am. 2003;85-A(1):66–71. 2012;20(2):149–61.
65. Maffet MW, Gartsman GM, Moseley B. Superior 78. Chung CB, Dwek JR, Feng S, Resnick D. MR arthrog-
labrum-biceps tendon complex lesions of the shoul- raphy of the glenohumeral joint: a tailored approach.
der. Am J Sports Med. 1995;23(1):93–8. AJR Am J Roentgenol. 2001;177(1):217–9.
66. Powell SE, Nord KD, Ryu RKN. The diagnosis, 79. Farmer KD, Hughes PM. MR arthrography of
classification, and treatment of SLAP lesions. Oper the shoulder: fluoroscopically guided technique
Tech Sports Med. 2004;12(2):99–110. using a posterior approach. AJR Am J Roentgenol.
67. Mohana-Borges AVR, Chung CB, Resnick 2002;178(2):433–4.
D. Superior labral anteroposterior tear: classification 80. Dépelteau H, Bureau NJ, Cardinal E, Aubin B,
and diagnosis on MRI and MR arthrography. Am J Brassard P. Arthrography of the shoulder: a simple
Roentgenol. 2003;181(6):1449–62. fluoroscopically guided approach for targeting
68. Clavert P, Bonnomet F, Kempf JF, Boutemy P, Braun the rotator cuff interval. AJR Am J Roentgenol.
M, Kahn JL. Contribution to the study of the patho- 2004;182(2):329–32.
genesis of type II superior labrum anterior-posterior 81. Wagner SC, Schweitzer ME, Weishaupt D. Temporal
lesions: a cadaveric model of a fall on the outstretched behavior of intra-articular gadolinium. J Comput
hand. J Shoulder Elb Surg. 2004;13(1):45–50. Assist Tomogr. 2001;25(5):661–70.
69. Bey MJ, Elders GJ, Huston LJ, Kuhn JE, Blasier 82. Vahlensieck M, Sommer T, Textor J, Pauleit D,
RB, Soslowsky LJ. The mechanism of creation of Lang P, Genant HK, et al. Indirect MR arthrog-
superior labrum, anterior, and posterior lesions in a raphy: techniques and applications. Eur Radiol.
dynamic biomechanical model of the shoulder: the 1998;8(2):232–5.
role of inferior subluxation. J Shoulder Elb Surg. 83. Bergin D, Schweitzer ME. Indirect mag-
1998;7(4):397–401. netic resonance arthrography. Skelet Radiol.
70. Burkhart SS, Morgan CD. The peel-back mecha- 2003;32(10):551–8.
nism: its role in producing and extending posterior 84. Bencardino JT, Beltran J, Rosenberg ZS, Rokito
type II SLAP lesions and its effect on SLAP repair A, Schmahmann S, Mota J, et al. Superior
rehabilitation. Arthrosc J Arthrosc Relat Surg. labrum anterior-posterior lesions: diagnosis with
1998;14(6):637–40. MR arthrography of the shoulder. Radiology.
71. Pagnani MJ, Deng XH, Warren RF, Torzilli PA, 2000;214(1):267–71.
Altchek DW. Effect of lesions of the superior portion 85. Waldt S, Burkart A, Lange P, Imhoff AB, Rummeny
of the glenoid labrum on glenohumeral translation. J EJ, Woertler K. Diagnostic performance of MR
Bone Joint Surg Am. 1995;77(7):1003–10. arthrography in the assessment of superior labral
72. Hantes ME, Venouziou AI, Liantsis AK, Dailiana anteroposterior lesions of the shoulder. Am J
ZH, Malizos KN. Arthroscopic repair for chronic Roentgenol. 2004;182(5):1271–8.
anterior shoulder instability: a comparative 86. Chandnani VP, Yeager TD, DeBerardino T,
study between patients with Bankart lesions and Christensen K, Gagliardi JA, Heitz DR, et al.
patients with combined Bankart and superior Glenoid labral tears: prospective evaluation with
labral anterior posterior lesions. Am J Sports Med. MRI imaging, MR arthrography, and CT arthrogra-
2009;37(6):1093–8. phy. Am J Roentgenol. 1993;161(6):1229–35.
87. Amin MF, Youssef AO. The diagnostic value of 100. Murray PJ, Shaffer BS. Clinical update: MR imag-
magnetic resonance arthrography of the shoulder ing of the shoulder. Sports Med Arthrosc Rev.
in detection and grading of SLAP lesions: com- 2009;17(1):40–8.
parison with arthroscopic findings. Eur J Radiol. 101. Gusmer PB, Potter HG, Schatz JA, Wickiewicz TL,
2012;81(9):2343–7. Altchek DW, O’Brien SJ, et al. Labral injuries: accu-
88. Magee T, Williams D, Mani N. Shoulder MR racy of detection with unenhanced MR imaging of
arthrography: which patient group benefits most? the shoulder. Radiology. 1996;200(2):519–24.
AJR Am J Roentgenol. 2004;183(4):969–74. 102. Connell DA, Potter HG, Wickiewicz TL, Altchek
89. Herold T, Hente R, Zorger N, Finkenzeller DW, Warren RF. Noncontrast magnetic resonance
T, Feuerbach S, Lenhart M, et al. Indirect imaging of superior labral lesions. 102 cases con-
MR-arthrography of the shoulder-value in the firmed at arthroscopic surgery. Am J Sports Med.
detection of SLAP-lesions. RöFo Fortschritte 1999;27(2):208–13.
Auf Dem Geb Röntgenstrahlen Nukl. 103. Magee T. 3-T MRI of the shoulder: is MR
2003;175(11):1508–14. arthrography necessary? Am J Roentgenol.
90. Dinauer PA, Flemming DJ, Murphy KP, Doukas 2009;192(1):86–92.
WC. Diagnosis of superior labral lesions: compari- 104. Major NM, Browne J, Domzalski T, Cothran RL,
son of noncontrast MRI with indirect MR arthrog- Helms CA. Evaluation of the glenoid labrum with
raphy in unexercised shoulders. Skelet Radiol. 3-T MRI: is intra-articular contrast necessary? Am J
2007;36(3):195–202. Roentgenol. 2011;196(5):1139–44.
91. Jung JY, Yoon YC, Yi S-K, Yoo J, Choe 105. Gustas CN, Tuite MJ. Imaging update on the glenoid
B-K. Comparison study of indirect MR arthrography labrum: variants versus tears. Semin Musculoskelet
and direct MR arthrography of the shoulder. Skelet Radiol. 2014;18(4):365–73.
Radiol. 2009;38(7):659–67. 106. Sasaki T, Yodono H, Prado GLM, Saito Y, Miura H,
92. Collins CM, Smith MB. Signal-to-noise ratio and Itabashi Y, et al. Increased signal intensity in the nor-
absorbed power as functions of main magnetic field mal glenoid labrum in MR imaging: diagnostic pit-
strength, and definition of “90 degrees ” RF pulse falls caused by the magic-angle effect. Magn Reson
for the head in the birdcage coil. Magn Reson Med. Med Sci. 2002;1(3):149–56.
2001;45(4):684–91. 107. Chang D, Mohana-Borges A, Borso M, Chung
93. Edelstein WA, Glover GH, Hardy CJ, Redington CB. SLAP lesions: anatomy, clinical presentation,
RW. The intrinsic signal-to-noise ratio in NMR MR imaging diagnosis and characterization. Eur J
imaging. Magn Reson Med. 1986;3(4):604–18. Radiol. 2008;68(1):72–87.
94. Ramnath RR. 3T MR imaging of the musculo- 108. Tuite MJ, Rutkowski A, Enright T, Kaplan L, Fine
skeletal system (part I): considerations, coils, and JP, Orwin J. Width of high signal and extension pos-
challenges. Magn Reson Imaging Clin N Am. terior to biceps tendon as signs of superior labrum
2006;14(1):27–40. anterior to posterior tears on MRI and MR arthrog-
95. Matzat SJ, van Tiel J, Gold GE, Oei EHG. Quantitative raphy. AJR Am J Roentgenol. 2005;185(6):1422–8.
MRI techniques of cartilage composition. Quant 109. De Maeseneer M, Van Roy F, Lenchik L, Shahabpour
Imaging Med Surg. 2013;3(3):162–74. M, Jacobson J, Ryu KN, et al. CT and MR arthrog-
96. Anz AW, Lucas EP, Fitzcharles EK, Surowiec RK, raphy of the normal and pathologic anterosuperior
Millett PJ, Ho CP. MRI T2 mapping of the asymp- labrum and labral-bicipital complex. Radiographics.
tomatic supraspinatus tendon by age and imaging 2000;20:S67–81.
plane using clinically relevant subregions. Eur J 110. Kwak SM, Brown RR, Trudell D, Resnick
Radiol. 2014;83(5):801–5. D. Glenohumeral joint: comparison of shoul-
97. Mosher TJ. Musculoskeletal imaging at 3T: current der positions at MR arthrography. Radiology.
techniques and future applications. Magn Reson 1998;208(2):375–80.
Imaging Clin N Am. 2006;14(1):63–76. 111. Yeh L, Kwak S, Kim YS, Pedowitz R, Trudell D,
98. Magee TH, Williams D. Sensitivity and specificity Muhle C, et al. Anterior labroligamentous struc-
in detection of labral tears with 3.0-T MRI of the tures of the glenohumeral joint: correlation of MR
shoulder. Am J Roentgenol. 2006;187(6):1448–52. arthrography and anatomic dissection in cadavers.
99. Legan JM, Burkhard TK, Goff WB, Balsara ZN, Am J Roentgenol. 1998;171(5):1229–36.
Martinez AJ, Burks DD, et al. Tears of the glenoid 112. Palmer WE, Brown JH, Rosenthal DI. Labral-
labrum: MR imaging of 88 arthroscopically con- ligamentous complex of the shoulder: evaluation with
firmed cases. Radiology. 1991;179(1):241–6. MR arthrography. Radiology. 1994;190(3):645–51.
Part IV
Trauma and Arthropathies
Imaging Diagnosis of Shoulder
Girdle Fractures 9
Joseph S. Yu
9.1 Introduction vascular structures, and fluid collections that may

have developed as a result of acute trauma. MRI is
The shoulder is vulnerable to both direct and indi- preferred for shoulder instability, but in the setting
rect trauma, and fractures and dislocations are of acute trauma its role is limited to depicting mar-
relatively common [1]. The shoulder girdle refers row edema that is associated with acute contusions
to a complex region of the skeleton that consists and occult fractures as well as for patients present-
of numerous muscular and osseous structures, ing with significant soft-tissue injuries.
several joints containing fibrocartilage and hya-
line cartilage, and ligaments and tendons that
attach and suspend the arm to the thorax allowing 9.2 Clavicle
for maximum mobility of the upper extremity.
Muscles act synergistically to optimize motion. 9.2.1 Pertinent Imaging Findings
Evaluation of the shoulder typically begins
with a radiographic inspection of the osseous The clavicle is an S-shaped bone that is unique,
structures and joints. There are limitations asso- functioning as an osseous connection between
ciated with the radiographic evaluation. Certain the arm and the trunk. It is therefore vulnerable to
fractures are difficult to visualize unless specific trauma especially in children and adolescents. It
projections are performed. Complex fractures or is one of the first bones to ossify, though the
fracture-dislocation complexes often are difficult medial epiphysis does not fuse until the second
to characterize owing to displacement of osseous decade of life. Radiographic examination typi-
fragments. Multi-detector CT has enabled rapid cally includes an AP view and a 35- to 40-degree
and accurate assessment of osseous and articular cephalad-angled projection called the serendipity
injuries. Depiction in an infinite number of imag- view. Owing to the curved contour of the bone,
ing planes and three-dimensional (3D) images the serendipity view offers better visualization of
has rendered CT an indispensable modality for the clavicle in its entirety and the sternoclavicular
assessment of acute shoulder trauma. joints. Medially, it is tubular with a broad head
Ultrasound is not routinely utilized in patients that articulates with the manubrium and the first
presenting with shoulder fractures but it is a useful rib. Laterally, the clavicle becomes flatter with a
follow-up modality for assessing the rotator cuff, discoid end that forms a gliding synovial joint
with the acromion process. The AP view allows
J. S. Yu (*) ideal inspection of the middle-third of the bone
Department of Radiology, The Ohio State University while the Zanca view (10-degree cephalad view)
Wexner Medical Center, Columbus, OH, USA
optimizes the acromioclavicular joint region.
e-mail: joseph.yu@osumc.edu

192 J. S. Yu
When evaluating complex or comminuted frac- injury. Angulation and displacement occur from the
tures, CT is optimal for assessment of displacement, pull of the sternocleidomastoid muscle on the
angulation, and injury to the adjacent neurovascular medial fragment and depression of the lateral frag-
structures. In general, thin-section protocols are rec- ment from the weight of the arm [5]. The degree of
ommended. MRI is occasionally employed to eval- displacement is usually more conspicuous on the
uate trauma to the muscles that insert on the clavicle serendipity or Zanca view than on the AP view (Fig.
including the pectoralis major, deltoid, trapezius, 9.1). When a fracture is severely comminuted, CT
and sternocleidomastoid muscles. may be indicated to assess for a concomitant injury
to the subclavian artery, particularly in the setting of
a rapidly growing hematoma, or to the subclavian
9.2.2 Clavicular Fractures vein and brachial plexus (Fig. 9.2).
Lateral third fractures account for 15% of clav-
9.2.2.1 Definition icle fractures (Fig. 9.3) [6]. The Neer classification
Typically, young people are at risk for clavicle is dependent on the location of the fracture with
fractures. Children and adolescents engage in respect to the coracoclavicular (CC) ligament
activities that subject them to accidents and falls. which consists of a conoid (medial) and trapezoid
In one study, falls during play or an athletic activ- (lateral) component. A type 1 fracture is located
ity were the etiology of a fracture in greater than lateral to the CC ligament and has minimal dis-
90% of cases [2]. The point of the shoulder was placement. A type 2a fracture occurs medial to the
usually the site of impact. Additional mecha- conoid component where a type 2b occurs between
nisms of injury include direct impaction on the the fibers of the CC ligament, disrupting the conoid
clavicle from assault or motor vehicle accidents component. Type 2 injuries can lead to significant
and rarely a fall on an outstretched hand. Birth separation between the coracoid process and the
trauma may place excessive pressure of the clavicle. Because it has the highest risk for non-
shoulder against the maternal symphysis pubis union, it generally requires surgical fixation. A
producing a characteristic fracture at the junction type 3 fracture is intra-articular, thus predisposing
of the middle and lateral thirds of the bone [3]. to arthritis. A type 4 fracture occurs in pediatric
patients with the displacement at the junction of
9.2.2.2 Radiographic and CT Findings the metaphysis and the growth plate. A type 5 frac-
The Allman classification divides the clavicle into ture is comminuted but contains a small inferior
thirds [4]. About 80% of clavicle fractures involve fragment that remains attached to the CC ligament
the middle third of the bone (Fig. 9.1). The majority and is similar to a type 2 variant.
of fractures are simple and transversely oriented; Less than 5% of clavicle fractures involve the
however, comminuted fractures associated with medial third (Fig. 9.4). These are difficult to visu-
butterfly fragments are not uncommon. In children, alize if not displaced owing to the overlap of the
fractures may be either a greenstick or bowing-type ribs and spine. Since these fractures are caused
by direct trauma, CT is useful to further charac-
terize the fracture to assess the surrounding
structures and to evaluate the sternoclavicular

joint. There are two types: transverse fractures
and intra-articular fractures.
9.2.2.3 Ultrasound Findings

Currently, sonography is not routinely used in
adults with clavicle fractures except to diagnose
vascular complications such as a pseudoaneurysm
Fig. 9.1 Clavicle fracture, nondisplaced. The majority of
or the formation of a hematoma. Sonography,
clavicle fractures involve the middle one-third of the clav-
icle (arrow). Imaging both clavicles with 10° of cephalad however, is commonly utilized in neonates to
angulation optimizes assessment of the angular deformity visualize clavicular birth fractures [7].
9 Imaging Diagnosis of Shoulder Girdle Fractures 193
a b
Fig. 9.2 Clavicle fracture, comminuted. (a) A commi- the lateral fragment. (b) CT is recommended when there
nuted mid-clavicular fracture (arrow) is frequently dis- is significant displacement of the clavicle fragments
placed from the pull of the sternocleidomastoid muscle on (arrow) to evaluate the vascular structures (curved arrow)
the medial fragment while the weight of the arm depresses and the brachial plexus
a b
Fig. 9.3 Distal clavicular fractures. (a) This patient had a from the coracoid process. (b) A different patient with a
Neer type 2 fracture occurring medial to the coracocla- type 5 fracture with an inferior fragment still attached to
vicular (CC) ligament, resulting in a fragment in anatomic the CC ligament, another fragment attached to the AC
alignment with the acromioclavicular (AC) joint (arrow) joint, and the rest of the clavicle (curved arrow) dis-
and marked superior migration of the rest of the clavicle placing superiorly
9.2.2.4 MR Findings 9.2.3 Postoperative Imaging

On occasion, MRI may be used to evaluate a
clavicle fracture when there is a simultaneous Most clavicular fractures heal without sequela
muscle injury or accumulation of a pathologic although a nonunion occurs in 1–4% of patients
fluid collection. When the soft tissues protrude [8]. When fixation is required, radiographic fol-
above the clavicle or into the axilla, for example, low-up is sufficient with standard clavicle projec-
it may be an indication that there is an enlarging tions. There are two common fixation techniques
hematoma from an occult vascular injury. employed. For midshaft fractures, uni-cortical
194 J. S. Yu
9.3.2 Sternoclavicular Joint Injuries
9.3.2.1 Definition
Dislocation of the SC joint is uncommon account-
ing for 2–3% of all shoulder girdle dislocations
[11]. Anterior dislocations are overwhelmingly
more common than posterior dislocations but the
latter type can be more severe because of associ-
ated injuries to adjacent structures. The mecha-
nism of injury for anterior dislocations is most
often indirect trauma with impaction to the ante-
rior shoulder with the clavicle acting as a ful-
Fig. 9.4 Medial clavicle fracture. Fractures involving the crum. Posterior dislocation usually occurs as a
medial clavicle (arrow) are uncommon but are frequently result of a direct blow against the medial clavicle.
overlooked owing to the overlap of the spine and ribs Complete disruption of the SC joint may result in
scapulothoracic dissociation.
plate fixation is common with the plate on the
superior cortical margin with screws directed 9.3.2.2 Radiographic and CT Findings
inferiorly in order to avoid the neurovascular Diagnosis of a SC joint dislocation is challenging
structures [9]. For distal type 2 clavicle fractures, on AP radiographs and this abnormality is fre-
it is not uncommon to see a variation of a clavicle quently missed on initial inspection. Detection
hook plate that has an S-shaped contour so that requires asymmetry of the joint space which may
the lateral end can be placed underneath the infe- not be evident with minor subluxation unless
rior margin of the acromion process [10]. there is also superior subluxation (Fig. 9.5). The
Allman classification defines three types [3]. In a
type 1 dislocation, there is partial disruption of the
9.3 Sternoclavicular Joint SC ligaments. In type 2, there is complete rupture
of the SC ligaments. In type 3, the SC ligaments
9.3.1 Pertinent Imaging Findings and the costoclavicular ligament are torn.
The modality of choice for confirmation is
The sternoclavicular (SC) joint is a di-arthrodial CT. Rapidly acquired images display the direc-
joint at the medial end of the clavicle. The disc tion of the dislocation, degree of osseous dis-
within the SC joint divides the gliding synovial placement, presence of any associated fracture,
joint into medial and lateral compartments. as well as any potential complication to the adja-
Supporting the joint are the interclavicular, costo- cent structures such as the great vessels.
clavicular, anterior sternoclavicular, and poste- Approximately 25% of posterior dislocations are
rior sternoclavicular ligaments. Radiographic associated with a laceration of the superior vena
evaluation consists of a PA view of both SC joints cava, thoracic outlet syndrome from venous com-
with the beam centered over the manubrium, and pression, compression of the recurrent laryngeal
bilateral PA oblique projections. It is important to nerve, pneumothorax or pneumomediastinum
confirm symmetric position of the clavicular from esophageal or tracheal rupture, or injury to
head and when in doubt CT is confirmatory. The the subclavian or carotid artery [12].
rhomboid fossa is a variant that occurs in the
inferomedial aspect of the clavicle corresponding 9.3.2.3 Ultrasound Findings
to the insertion of the costoclavicular ligament. It Ultrasound has been described as a potential
is depicted by an irregular concavity located lat- screening tool to assess possible sternoclavicular
eral to the head of the clavicle and is seen com- dislocation [13].
monly in males.
a b
Fig. 9.5 Sternoclavicular joint (SC) separation. (a) caused by posterior dislocation of the right clavicular
Frontal radiograph of the chest shows asymmetric eleva- head (arrow). When this occurs, it is important to thor-
tion of the right clavicular head (arrow) compared to the oughly evaluate the vascular structures
left. (b) Axial CT image shows that the asymmetry is
9.3.2.4 MR Findings clavicle containing a variably developed intra-

The multiplanar capabilities of MRI along with articular disc. This synovial joint is supported
its superior soft tissue resolution have made this by the capsule, the AC ligaments, and the CC
modality particularly effective for characterizing ligament. Radiographic evaluation consists of
ligamentous tears and cartilaginous injuries [14]. an AP view of the upper thorax including AC
MR angiography is very helpful in elucidating joints and a 15-degree cephalad-angled view
occult vascular injury as well. and symmetry with the contralateral joint is a
key observation. If findings are equivocal or sur-
gery is contemplated, bilateral weight-bearing
9.3.3 Postoperative Imaging stress views may be performed to confirm the
severity of pathology. The normal width of the
The treatment of choice for SC dislocations is AC joint is 2–6 mm and it decreases with age
closed reduction and immobilization of the arm [16]. Any discrepancy of the CC distance greater
with a sling [15]. Delay in diagnosis may lead to than 3–4 mm, or asymmetry of the AC joint
instability; stabilization procedures of the SC space greater than 2 mm, may indicate a rupture
joint with a trans-osseous tension band or liga- of the CC ligament. An axillary view is useful
mentous reconstruction are potential long-term especially when there is concern of a posterior
solutions. However, in some patients, resection subluxation. Though not routinely used, MRI is
arthroplasty of the medial end of the clavicle is an excellent modality that enables comprehen-
the only option for treating persistently painful sive evaluation of the osseous structures and
SC joints. soft-tissue stabilizers of this joint.
9.4 Acromioclavicular Joint 9.4.2 Acromioclavicular Joint

Injuries
9.4.1 Pertinent Imaging Findings
9.4.2.1 Definition
The acromioclavicular (AC) joint is a di- The AC joint is the second most commonly dislo-
arthrodial gliding joint at the lateral end of the cated joint in the shoulder accounting for about
196 J. S. Yu
12% of all shoulder dislocations [17]. Two injury

mechanisms are responsible, either a direct fall
on the shoulder or a fall on an outstretched hand.
The force applied determines the spectrum of
pathology. The initial injury is a strain of the AC
ligaments. As the force increases, the trapezoid
component of the CC ligament ruptures then fol-
lowed by the conoid component as the force is
increased. With complete rupture of the CC liga-
ment, the clavicle is allowed to detach resulting
in injuries to the insertion of the deltoid and tra-
pezius muscles.

A six-point grading system is used to classify
and treat AC joint injuries [18]. A grade 1 sepa- Fig. 9.6 Acromioclavicular (AC) joint separation, type 2.
ration indicates stretching of the AC ligaments The distal clavicle (arrow) elevates superiorly by about
without capsular disruption. Radiographs half of the shaft width relative to the acromion process
owing to a rupture of the AC ligament and partial tears of
appear normal or may show mild soft-tissue the coracoclavicular ligaments
swelling over the joint. A grade 2 separation
results in disruption of the AC ligaments and an
incomplete tear of the CC ligament (Fig. 9.6). 9.4.2.4 MR Findings
The clavicle elevates superiorly but usually less MRI is a useful tool for assessment of AC joint
than 50% of the width of the clavicle and the AC pain and it has recently been advocated for eval-
joint widens compared to the contralateral joint, uation of acute AC joint separations [19]. The
particularly with weight-bearing views. A grade main limitation of radiography is accuracy in the
3 separation is a true dislocation with complete categorization of the injury and this may have an
rupture of the AC and CC ligaments (Fig. 9.7). effect on the treatment. MR enables distinction
A variation can occur in people younger than between grade 2 and 3 injuries and also has been
25 years of age depicted by an avulsion fracture shown to reclassify radiographic grading to a
at the base of the coracoid process but with an lesser type in as many as 36% of patients and to
intact CC ligament. a more severe type in greater than 11% of
The three latter grades are uncommon. In patients [20].
grade 4 injuries, the clavicle displaces posteriorly
into or through the trapezius muscle. In grade 5
injuries, elevation of the clavicle is more severe 9.4.3 Postoperative Imaging
than in a grade 3 separation. In grade 6 injuries,
the clavicle dislocates inferiorly below the cora- There are several surgical options in the manage-
coid or acromion process often occurring with ment of AC joint dislocations [21, 22]. Current
associated rib fractures. evidence suggests that operative management of
type 3 fractures has better results. Early surgery
9.4.2.3 Ultrasound Findings has been reported to have better cosmetic and
Ultrasound may be used to screen for AC joint radiologic outcomes and a lower risk for infec-
separation but it is suggested only if CT or MRI tion, and reduce the overall incidence of failed
is not available. surgery.
a b
Fig. 9.7 Acromioclavicular (AC) joint separation, type 3. process. (b) Sagittal T2-weighted MR image shows com-
(a) Frontal radiograph shows complete disarticulation of the plete disruption of the coracoclavicular ligaments (curved
clavicle (arrow) from the acromion process and an abnor- arrow) and a hematoma (arrow) where the superior AC liga-
mally wide distance between the clavicle and the coracoid ment is typically visualized. [C—coracoid]
9.5 Scapula of an apophysis (which generally occurs by

25 years of age) appearing as a transverse lucency.
9.5.1 Pertinent Imaging Findings It is common and occurs in 7–10% of people [23].
True fractures of the acromion process usually
The scapula is a large, triangular flat bone located occur at the junction of the spine and the acro-
in the dorsolateral aspect of the thorax that is mion. One pitfall is a chronic fracture with non-
almost entirely surrounded by muscles. Because union which may be impossible to d ifferentiate
the body of the scapula is anteverted 30–40° with from a basi-acromial type of os acromiale unless
respect to the coronal plane of the body, a true AP there are comparison radiographs.
view of the scapula is actually an AP oblique
radiograph of the shoulder. This projection allows
visualization of the superior and inferior angles 9.5.2 Scapular Fractures
in the medial aspect of the blade, the superior and
lateral borders, the tip of the coracoid process, 9.5.2.1 Definition
the majority of the spine, the portion of the acro- Scapular fractures account for 3–5% of fractures
mion that articulates with the clavicle, and the in the shoulder girdle [24]. Fractures of the scap-
glenoid neck and fossa. A lateral projection, or ula require major trauma with either axial load-
Y-view, allows assessment of the body, acromion, ing on an outstretched arm or direct forces aimed
and base of the spine. An axillary view depicts at the scapula such as those that occur from a fall
the acromion and coracoid processes as well as from a height, motor vehicular trauma, or crush-
the glenoid fossa and neck. CT, on the other hand, ing injury. Fractures of the glenoid rim and cora-
is preferred when there is a complex fracture of coid process may also occur with glenohumeral
the scapula particularly when performed with 3D joint dislocations. There are numerous classifica-
reconstruction. tion systems for describing scapular fractures but
Ossification centers have a typical radiographic none predominate; thus, fractures often are
appearance and should not be mistaken for a frac- described according to the anatomic area involved
ture. An os acromiale represents failure of fusion including the acromion process, coracoid process,
198 J. S. Yu
scapular neck, and glenoid fossa/rim with the lat- not displaced and has two subtypes: avulsive type
ter subdivided into extra- and intra- articular 1a and impactive type 1b. A type 2 fracture is dis-
types. The majority of fractures involve the body placed but does not encroach on the subacromial
and inferior glenoid neck and over 20% enters space. A type 3 fracture is either inferiorly dis-
the spinoglenoid notch [25]. placed or associated with a superiorly displaced
glenoid fracture. Coracoid and acromion frac-
9.5.2.2 Radiographic and CT Findings tures may be radiographically occult or difficult
Fractures of the body constitute the most com- to visualize. Axillary views and trans-scapular Y
mon fracture of the scapula. The Grashey and views are considered essential projections for
lateral projections are useful since these frac- depicting fractures of either bony tubercle.
tures, though often comminuted, have conspicu- Glenoid fractures are categorized as either
ous vertical and/or horizontal components. extra-articular or intra-articular [27]. In extra-
Fractures through the scapular neck are fre- articular fractures, the integrity of the clavicle
quently displaced and are unstable if the clavicle and AC joint is important (Fig. 9.9). Intra-
and CC ligament are also disrupted. articular fractures comprise about 10% of scapu-
Coracoid fractures are categorized according lar fractures and is most commonly classified
to where the fracture is located with respect to the according to the classification described by
CC ligament attachment (Fig. 9.8). A type 1 frac- Ideberg (Fig. 9.10) [28]. Type 1a is most com-
ture occurs proximal to the CC ligament and may mon and represents an anterior chip fracture of
be associated with AC joint separation, fractures the glenoid rim. Type 1b is through the posterior
of the clavicle, and/or other scapular fractures glenoid rim. Type 2 is a transverse or an oblique
involving the superior scapula and glenoid [26]. fracture through the inferior glenoid fossa with
A type 2 fracture occurs distal to the CC liga- inferior displacement. Type 3 is a transverse frac-
ment. Acromion process fractures are usually ture through the superior glenoid fossa and
transversely oriented at its base. Three types have extending to the superior border. Type 4 is a
been described by Kuhn et al. A type 1 fracture is transverse fracture through the body extending to
a b
Fig. 9.8 Coracoid fracture, type 1. (a) Frontal radiograph arrow). (b) The scapular Y-view offers a second opportu-
shows cortical disruption near the base of the coracoid pro- nity to observe this fracture (arrows) since it is often
cess (arrow). There is also a type 3 AC separation (curved obscured in the frontal projection owing to bony overlap
Approximately 25–43% of scapular fractures

are not detected initially [29]. Scapular fractures
are frequently associated with other injuries to
the rib, clavicle, spine, extremities, lung, vascular
structures, and brachial plexus or central nervous
system. These injuries have been reported in
81–98% of scapular fractures [24, 30]. 3DCT is
optimal for evaluating these fractures since it
reliably identifies extension to the superior,
medial, and lateral borders which are clinically
relevant [31].
9.5.2.3 Ultrasound Findings

Ultrasound has been useful for diagnosing occult
coracoid fractures but otherwise is not generally
employed for assessment of this bone [32].
9.5.2.4 MR Findings

Fig. 9.9 Scapular fracture, extra-articular type. Extra- MRI allows simultaneous inspection of the bone
articular fractures (arrows) are frequently associated with and the ligaments of the shoulder girdle but is
concomitant injuries of the clavicle (curved arrow) and best reserved as a follow-up study after the osse-
acromioclavicular joint
ous injuries have been ascertained acutely. It is
useful for the evaluation of compartment syn-
drome of the scapula.
9.5.3 Postoperative Imaging
The majority of scapular fractures are treated

conservatively but because closed reduction is
not possible malalignment is a common outcome.
Intra-articular fractures that are complex do well
with surgery [33, 34]. The goal is to restore sta-
bility to the glenoid when fractures are displaced
more than 1 cm or more than 25% of the articular
surface is involved. Scapular neck fractures may
be repaired if medially displaced more than 1 cm
or angulated more than 40°.
Fig. 9.10 Scapular fracture, intra-articular type. Fractures 9.6 Glenohumeral Joint
that involve the glenoid fossa and rim are considered intra-
articular. The location of the fracture in the fossa is useful
for its characterization. This patient has an Ideberg type 4 9.6.1 Pertinent Imaging Findings
fracture extending from the fossa to the medial border
The glenohumeral joint is a spheroidal joint that
the medial border. Type 5 is a type 4 with separa- has the distinction of being the most mobile artic-
tion of the glenoid. Type 6 is a comminuted ulation in the body. The range of motion afforded
fracture. by this joint is related to the disproportionate
200 J. S. Yu
sizes of the articulating surfaces and the relative it can depict injuries involving the joint capsule,
lack of osseous constriction. What this joint has labrum, articular cartilage, tendons and support-
in mobility, however, it lacks in stability. It is the ing ligaments, as well as marrow edema that are
most commonly dislocated joint in the skeleton associated with bone contusions and occult
with 50% of dislocations affecting this articula- fractures.
tion [35]. Reportedly, shoulder dislocations occur
at a rate of 1–2% in the general population and
have an incidence of as high as 7% in selected 9.6.2 nterior Glenohumeral Joint
A
groups of athletes [36]. Anterior dislocations are Dislocation
most common. Posterior dislocations are often
difficult to diagnose. Inferior dislocations, 9.6.2.1 Definition
referred to as luxatio erecta, are caused by either Anterior dislocation accounts for about 95% of
hyperabduction of the arm or a direct blow all glenohumeral joint dislocations. Four types of
against the length of the arm with the shoulder anterior dislocations have been described depend-
maximally abducted. Superior dislocations are ing on the location of the humeral head after it
rare and caused by forces directed cephalad along has become dislocated: subcoracoid, subclavicu-
an adducted arm. lar, subacromial, and intrathoracic. The majority
Evaluation of trauma usually begins with a of anterior dislocations are caused by abduction
three- or four-view radiographic series that with forced external rotation of the arm, although
include an AP, oblique AP (Grashey), lateral Y, a direct blow to the back of the shoulder may be
and axillary projections. It is generally recom- an occasional cause [37].
mended that the AP view be performed with the
arm in neutral position or internally rotated, and 9.6.2.2 Radiographic and CT Findings
the Grashey view be performed with the humerus Radiographic diagnosis of an anterior dislocation
externally rotated to allow a more complete is not difficult. The most common type of ante-
depiction of the humeral head. Internal rotation rior dislocation is a subcoracoid dislocation char-
depicts the anterior and posterior articular sur- acterized by anterior, inferior, and medial
faces and brings the lesser tuberosity cortex into displacement of the humeral head beneath the
profile. External rotation, on the other hand, coracoid process (Fig. 9.11). A subglenoid
brings the greater tuberosity into full profile and dislocation is characterized by anterior, inferior,
enables much of the medial articular surface to be and more medial displacement of the humeral
visualized. An advantage of the Grashey view head so that it comes to rest beneath the inferior
over the AP shoulder projection is that it elimi- rim of the glenoid. A subclavicular dislocation
nates the overlap of the glenoid rim and the results in anterior, inferior, and even more medial
humeral joint. The nearly spherical head articu- displacement so that the humeral head terminates
lates with the glenoid fossa much like a golf ball beneath the clavicle. Lastly, an intrathoracic ante-
sitting on a tee. The axial view is optimal in rior dislocation occurs when the humeral head
showing subtle decentering of the humerus that penetrates an intercostal space.
may not be detectable on other radiographic pro- The shoulder girdle must be scrutinized for
jections and to depict hypertrophic osseous certain injuries after a dislocation. A Hill-Sachs
changes in the glenoid rim that may herald an lesion, an impaction fracture of the posterolateral
underlying labral abnormality. aspect of the humeral head, occurs when the
When there is an injury of the glenohumeral humeral head becomes perched against the infe-
joint, CT is an excellent imaging tool for further rior aspect of the anterior glenoid rim [38]. It is
characterizing the humeral head and glenoid. detectable as a wedge-shaped or concave defect
However, it does not show the connective and in the posterolateral aspect of the head when it is
cartilaginous tissues as well as MRI, even in the internally rotated. It is best depicted on an AP
setting of arthrography. When MRI is necessary, shoulder view but a Stryker notch view is also
a b
Fig. 9.11 Anterior glenohumeral joint dislocation. (a) the most common type. (b) After reduction, a sclerotic lin-
The humeral head has dislocated anteriorly from the gle- ear abnormality (arrows) seen on an internally rotated
noid fossa and is located beneath the coracoid process view of the humerus defines the posteromedial border of
(arrow). The subcoracoid type of anterior dislocation is the Hill-Sachs lesion
useful. If the defect is sufficiently large, a linear ity which can be displaced or comminuted (Fig.
sclerotic band may be seen vertically oriented on 9.14) [40]. Another 2% of dislocations are asso-
the head which defines the posterior edge of the ciated with a fracture of the surgical neck of the
impaction fracture. CT is reliable for diagnosis humerus, scapular body, acromion process, and
and characterization. A Hill-Sachs lesion is dif- clavicle.
ferentiated from the normal trough by its more
superior location [39]. 9.6.2.3 Ultrasound Findings
In about 8% of patients, a concomitant frac- Sonography is a useful modality for evaluating
ture of the anteroinferior glenoid rim (osseous the rotator cuff in patients with shoulder instabil-
Bankart lesion) occurs but the reported incidence ity and for identifying Hill-Sachs lesions but is
has been as high as 31% (Fig. 9.12) [40]. Close overall inferior to MRI for characterization of
scrutiny on AP and lateral radiographs is required osseous lesions, capsular and ligamentous inju-
since the fragment of bone may be quite small but ries, and labral tears [42, 43].
a well-positioned lateral view is most optimal.
An uncommon avulsion fracture may occur at the 9.6.2.4 MR Findings
humeral attachment of the inferior glenohumeral MRI has become indispensable for the evaluation
ligament referred to as a BHAGL (bony humeral of shoulder instability [44]. Acute dislocations are
avulsion of the glenohumeral ligament) lesion characterized by bone marrow edema surround-
(Fig. 9.13). An osteochondral defect of the gle- ing a Hill-Sachs lesion and in the anterior glenoid
noid has also been associated with anterior dislo- rim as well. Pathologic entities that are occult or
cations and is usually occult unless large [41]. not easily seen on radiographs or CT include avul-
About 15–25% of anterior dislocations are sions and tears of the subscapularis tendon, strip-
associated with a fracture of the greater tuberos- ping of the capsule, and soft-tissue Bankart
202 J. S. Yu
Fig. 9.12 Osseous Bankart lesion. There is a displaced

fragment of bone arising from the anteromedial aspect of Fig. 9.14 Anterior shoulder dislocation with greater
the glenoid rim (arrow). The size of the fragment corre- tuberosity fracture. As the humeral head dislocates anteri-
lates with the degree of instability and if more than 25% orly, the force of impaction against the anterior glenoid
of the articular surface is involved surgical repair with the rim can produce a fracture through the greater tuberosity
Latarjet-Bristow (coracoid transfer) procedure (arrow) which often is displaced or comminuted
lesions, defined as an avulsion of the anterior

labrum by the anterior band of the inferior gleno-
humeral ligament associated with d isruption of
the anterior periosteum. Bankart variants with the
acronyms HAGL, ALPSA (anterior labroliga-
mentous periosteal sleeve avulsion), and GLAD
(glenoid labral articular disruption) lesions are
best characterized with MR arthrography [45].
9.6.3 osterior Glenohumeral Joint

P
Dislocation
9.6.3.1 Definition
Posterior dislocations are much less common
than anterior dislocations accounting for less
than 5% of glenohumeral dislocations [46]. The
mechanism of injury is either a fall on an out-
Fig. 9.13 Bony humeral avulsion of the glenohumeral stretched hand or a direct trauma to a flexed,
ligament (BHAGL) lesion. Coronal T2-weighted MR adducted, and internally rotated shoulder which
image shows an avulsed fragment of bone (arrow) arising
forces the humeral head posteriorly. There are
from the humeral attachment of the anterior band of the
inferior glenohumeral ligament. This lesion may mimic three types of posterior shoulder dislocations.
an osseous Bankart lesion on radiographs Nearly all, about 98%, are the subacromial type.
The posterior subglenoid and subspinous types detect radiographically and usually require CT
are uncommon. Bilateral dislocations are typi- for confirmation (Fig. 9.16).
cally associated with seizures. There are several important radiographic signs
that are associated with posterior shoulder disloca-
9.6.3.2 Radiographic and CT Findings tions [50]. These radiographic observations under-
The radiographic features of posterior disloca- score the difficulty in making this diagnosis
tions often are subtle so that over one-half of dis- (Fig. 9.17). The lightbulb sign is a persistently inter-
locations are still missed on initial inspection nally rotated arm on all views of a shoulder series
[47]. When the humeral head dislocates posteri- when the head is perched on the glenoid. The rim
orly, the stretched anterior musculature pulls it sign indicates a widened glenohumeral joint exceed-
back forcing it to impact against the posterior ing 6 mm in width. The crescent (absent half-moon)
glenoid rim. This creates a wedge-shaped impac- sign is absence of the normal overlap between the
tion, referred to as a trough lesion, in the antero- glenoid and humeral head. A disrupted scapulo-
medial aspect of the humeral head that is similar humeral arch indicates humeral head subluxation.
to a Hill-Sachs lesion (Fig. 9.15) [48]. It appears A lesser tuberosity fracture (25% incidence)
as a vertically oriented dense linear band that par- (Fig. 9.18) and humeral head fracture (10% inci-
allels the medial cortex of the humeral head on dence) are two additional observations that
internally rotated frontal radiographs of the should elicit a search for other indicators of a
shoulder. An axillary view is useful in character- posterior dislocation [48].
izing the size of the lesion. The incidence of a
trough lesion has been estimated to occur in 9.6.3.3 Ultrasound Findings
29–75% of all dislocations [48, 49]. Reverse Sonography has a limited role in patients with
osseous Bankart lesions are generally difficult to acute posterior shoulder instability.
a b
Fig. 9.15 Trough lesions in posterior glenohumeral joint image in another patient shows the effect of a chronic dis-
dislocations. (a) This patient shows a posteriorly dislo- location with the formation of a pseudoarthrosis with wid-
cated humerus with an impaction fracture in the anterior ening of the trough lesion (arrow) as it toggles on the
surface of the humeral head manifested as a linear verti- posterior glenoid rim
cally oriented area of sclerosis (arrows). (b) A 3D CT
204 J. S. Yu
9.6.3.4 MR Findings

The presence of bone marrow edema in the anterior
humeral head is consistent with an acute impaction
injury [51]. A reverse soft-tissue Bankart lesion
represents damage to the posterior labrum that
occurs either when the humeral head displaces pos-
teriorly or when it impacts the posterior glenoid
rim. The labrum may appear detached or frag-
mented, and the capsule may be stripped or torn.
9.6.4 Postoperative Imaging
The focus of this section is treatment of fractures

that have been sustained during a glenohumeral
joint dislocation. 3DCT and MRI are both useful
for assessing the size of glenoid and humeral
defects [52, 53].
Glenoid defects that exceed 25% of the
fossa usually require surgical management for
best results. The Latarjet-Bristow procedure is
Fig. 9.16 Reverse osseous Bankart lesion. A disarticu-
lated 3D CT image of the scapula shows a fracture of the
performed in patients with large osseous
posterior glenoid rim with a displaced fragment (arrow) in Bankart fractures and has been popularized
a patient who had sustained a posterior glenohumeral joint owing to excellent outcomes and a low risk for
dislocation recurrence [54]. In this open surgical proce-
a b
Fig. 9.17 Radiographic signs associated with a posterior is formed by the smooth transition of the cortical margins
shoulder dislocation. (a) A rim sign is present when the gleno- formed by the lateral scapula, inferior glenoid neck, surgical
humeral joint measures greater than 6 mm in width (arrow). neck of the humerus, and medial margin of the humeral shaft.
The humeral head does not have to sublux inferiorly or supe- In this patient, there is a break in the arch producing an angu-
riorly for this sign to be present. (b) This scapulohumeral arch lar deformity (black lines). Note that there is a rim sign as well
a b
Fig. 9.18 Lesser tuberosity fracture in a posterior shoul- tuberosity (arrow). (b) The axillary view shows a promi-
der dislocation. (a) Frontal radiograph shows that the nent trough defect (arrow) just medial to the lesser tuber-
humeral head is perched against the posterior glenoid rim osity fracture (curved arrow)
and there is double density seen in the region of the lesser
dure, a portion of the coracoid process is har- 9.7 Proximal Humerus

vested as a bone graft and then transferred to
the anterior glenoid along with the attached 9.7.1 Pertinent Imaging Findings
muscles, thus simultaneously replacing the
absent bone and providing an additional mus- In order to evaluate the humeral head and proximal
cular strut which stabilizes the anterior capsule shaft, shoulder radiographs performed with both
and reinforces the subscapularis tendon. internal and external rotation are necessary. The
Patients with large posterior glenoid defects proximal humerus is divided into four anatomic
can be effectively treated using the McLaughlin regions: the head, anatomic neck, surgical neck,
procedure which transfers the lesser tuberosity and greater and lesser tuberosities. When a frac-
with the attached subscapularis tendon into the ture occurs in the surgical neck, the axillary view
defect [55]. is most useful for demonstrating both angulation
Patients with large impaction defects of the and displacement. Complex fractures often require
humeral head show a dramatically lower inci- additional imaging with CT to further assess frac-
dence of recurrence with surgery. Several pro- ture orientation, displacement and rotation of bone
cedures have been effective including fragments, angulation, and impaction/overriding
transferring the infraspinatus tendon (remplis- for treatment and preoperative planning. When the
sage procedure), allograft humeral head recon- rotator cuff attachment is involved, MRI or ultra-
struction, and partial resurfacing arthroplasty sound may be useful for follow-up.
[56]. Allograft reconstruction utilizing cryo-
preserved femoral head allografts or bone
blocks has been performed with either anterior 9.7.2 Pathologic Conditions
or posterior defects when the defect involves
greater than 40% of the articular surface. In 9.7.2.1 Definition
severe cases, total arthroplasty may be the People who are in their sixth and seventh decades
option to prevent future dislocations. of life are susceptible to fractures of the proximal
206 J. S. Yu
humerus [57]. In this age group, the most com-

mon mechanism of injury is a fall on the out-
stretched hand. In younger people, more severe
trauma like those that occur from a motor vehicle
accident is responsible for humeral fractures. The
muscular insertions are noteworthy since the
actions of the rotator cuff, pectoralis, latissimus
dorsi, and teres major muscles can influence the
degree and direction of displacement of osseous
fragments.

Radiography is usually sufficient for diagnosis
but CT is superior for fracture characterization
particularly with 3D reconstruction. Isolated
fractures of the greater (Fig. 9.19) and lesser
tuberosities are uncommon and may be associ-
ated with rotator cuff insufficiency. The surgi-
cal neck is the most common location for
fractures in the proximal humerus (Fig. 9.20). Fig. 9.19 Avulsion fracture of the greater tuberosity. An
Frequently, these fractures are impacted and avulsion fracture of the greater tuberosity may be subtle if
extend to the greater tuberosity. Anterior and not displaced. An externally rotated view that depicts the
footplate is optimal. When displaced, it is important to
medial displacement of the shaft may occur in measure the separation since displacement can contribute
about 15–20% of patients owing to the action to rotator cuff insufficiency
of the pectoralis major muscle while the rest
usually are not significantly displaced [58]. tubercles remains attached to the humeral head,
Fractures of the anatomic neck are less com- the blood supply to the head is likely to remain
mon but can be complicated by avascular intact. Rotator cuff tears are common with this
necrosis from disruption of the blood supply to pattern of injury as well. About 4% of fractures
the humeral head. are four-part fractures and osteonecrosis is a
The Neer classification is a widely used clas- common complication.
sification because it provides predictive value to
treatment plans [59]. The classification takes into 9.7.2.3 Ultrasound Findings
account the number of fragments and the degree Sonography has a role in the diagnosis of humeral
of angulation and/or displacement, roughly fol- fractures in the neonatal period but in adults it has
lowing the anatomic lines of epiphyseal union. limited application in osteoporotic patients and for
Displacement from its anatomic position by more evaluation of occult fractures of the tuberosity [60].
than 1 cm or angulation by more than 45° is sig-
nificant. About 80% of fractures under this clas- 9.7.2.4 MR Findings
sification are one-part fractures without MRI is useful for further assessment of symp-
significant displacement or angulation. Another tomatic patients with an occult proximal humeral
10% are two-part fractures with displacement of fracture [61]. These include two important groups
shaft anteromedially with respect to the neck. of patients: adolescents with Salter-Harris inju-
Three-part fractures constitute about 3% of frac- ries and severely osteoporotic patients. MRI
tures with displacement of the surgical neck and depicts areas of marrow edema and areas of dis-
one of the tuberosities but as long as one of the rupted trabeculation.
a b
Fig. 9.20 Humerus fracture, surgical neck. (a) Fractures Neer classification is useful. This patient had a lesser
located at the surgical neck of the humerus are frequently tuberosity fracture (arrow) and a displaced greater tuber-
impacted and can extend to the greater tuberosity or lesser osity fragment (curved arrow), in addition to a surgical
tuberosity. (b) When multiple fragments are affected, the neck fracture
9.7.3 Postoperative Imaging 4. Allman FL. Fractures and ligamentous injuries of the
clavicle and its articulations. J Bone Joint Surg Am.
1967;49:774–84.
Radiographic findings of a greater tuberosity 5. Ridpath CA, Wilson AJ. Shoulder and humerus
fractures repair is much like a rotator cuff repair. trauma. Semin Musculoskelet Radiol. 2000;4:151–70.
There are a variety of open reduction and internal 6. Neer CS II. Fractures of the distal third of the clavicle.
Clin Orthop. 1968;58:43–50.
fixation techniques using intramedullary devices 7. Mavrogenis AF, Mitsiokapa EA, Kanellopoulos AD,
for surgical neck two-part fractures. Three- and Ruggieri P, Papagelopoulos PJ. Birth fracture of the
four-part fractures in elderly patients usually clavicle. Adv Neonatal Care. 2011;11:328–31.
involve either a hemiarthroplasty, reverse shoul- 8. Barger WL, Marcus RE, Ittleman FP. Late thoracic
outlet syndrome secondary to pseudoarthrosis of the
der arthroplasty, or complete conventional arthro- clavicle. J Trauma. 1984;24:847–59.
plasty [62, 63]. 9. Donnelly TD, Macfarlane RJ, Nagy MT, Ralte P,
Waseem M. Fractures of the clavicle: an overview.
Open Orthop J. 2013;7:329–33.
10. Renger RJ, Roukema GR, Reurings JC, Raams
References PM, Font J, Verleisdonk EJ. The clavicle hook plate
for Neer type II lateral clavicle fractures. J Orthop
1. Sheehan SE, Gaviola G, Sacks A, Gordon R, Shi LL, Trauma. 2009;23:570–4.
Smith SE. Traumatic shoulder injuries: a force mech- 11. Sewell MD, Al-Hadithy N, Le Leu A, Lambert
anism analysis of complex injuries to the shoulder SM. Instability of the sternoclavicular joint: current
girdle and proximal humerus. AJR Am J Roentgenol. concepts in classification, treatment and outcomes.
2013;201:W409–24. Bone Joint J. 2013;95-B:721–31.
2. Sankarankutty M, Turner BW. Fractures of the clavi- 12. Gove N, Ebraheim NA, Glass E. Posterior sterno-
cle. Injury. 1975;7:101–6. clavicular dislocations: a review of management and
3. Madsen ET. Fractures of the extremities in the new- complications. Am J Orthop. 2006;35:132–6.
born. Acta Obstet Gynecol Scand. 1955;34:41–7.
208 J. S. Yu
13. Ferri M, Finlay K, Popowich T, Jurriaans E, Friedman Orthopaedic Trauma Association (AO/OTA) scapula
L. Sonographic examination of the acromioclavicu- fracture classification system: focus on body involve-
lar and sternoclavicular joints. J Clin Ultrasound. ment. J Shoulder Elb Surg. 2014;23:189–96.
2005;33:345–55. 32. Botchu R, Lee KJ, Bianchi S. Radiographically unde-
14. Emberg LA, Potter HG. Radiographic evaluation of tected coracoid fractures diagnosed by sonography.
the acromioclavicular and sternoclavicular joints. Report of seven cases. Skelet Radiol. 2012;41:693–8.
Clin Sport Med. 2003;22:255–75. 33. Anavian J, Gauger EM, Schroder LK, Wijdicks CA,
15. Balcik BJ, Monseau AJ, Krantz W. Evaluation and Cole PA. Surgical and functional outcomes after oper-
treatment of sternoclavicular, clavicular, and acromio- ative management of complex and displaced intra-
clavicular injuries. Prim Care. 2013;40:911–23. articular glenoid fractures. J Bone Joint Surg Am.
16. Petersson CJ, Redlnd-Johnell I. Radiographic joint 2012;94:645–53.
space in normal acromioclavicular joint. Acta Orthop 34. Cole PA, Gauger EM, Herrera DA, Anavian J,
Scand. 1983;54:431–3. Tarkin IS. Radiographic follow-up of 84 operatively
17. Neviaser RJ. Injuries to the clavicle and acromiocla- treated scapula neck and body fractures. Injury.
vicular joint. Orthop Clin North Am. 1987;18:433–8. 2012;43:327–33.
18. Melenevsky Y, Yablon CM, Ramappa A, Hochman 35. Gyftopoulos S, Bencardino J, Palmer WE. MR
MG. Clavicle and acromioclavicular joint injuries: imaging of the shoulder: first dislocation versus
a review of imaging, treatment, and complications. chronic instability. Semin Musculoskelet Radiol.
Skelet Radiol. 2011;40:831–42. 2012;16:286–95.
19. Alyas F, Curtis M, Speed C, Saifuddin A, Connell 36. Hovelius L. Incidence of shoulder dislocation in
D. MR imaging appearances of acromioclavicular Sweden. Clin Orthop. 1982;166:127–31.
joint dislocation. Radiographics. 2008;28:463–79. 37. Bencardino JT, Gyftopoulos S, Palmer WE. Imaging
20. Nemec U, Oberleitner G, Nemec SF, Gruber M, in anterior glenohumeral instability. Radiology.
Weber M, Czerny C, et al. MRI versus radiography 2013;269:323–37.
of acromioclavicular joint dislocation. AJR Am J 38. Provencher MT, Frank RM, Leclere LE, Metzger PD,
Roentgenol. 2011;197:968–73. Ryu JJ, Bernhardson A, et al. The Hill-Sachs lesion:
21. Modi CS, Beazley J, Zywiel MG, Lawrence TM, diagnosis, classification, and management. J Am
Veillette CJ. Controversies relating to the manage- Acad Orthop Surg. 2012;20:242–52.
ment of acromioclavicular joint dislocations. Bone 39. Richards RD, Sartoris DJ, Pathria MN, Resnick
Joint J. 2013;95-B:1595–602. D. Hill-Sachs lesion and normal humeral groove:
22. Babhulkar A, Pawaskar A. Acromioclavicular joint dis- MR imaging features allowing their differentiation.
locations. Curr Rev Musculoskeletal Med. 2014;7:33–9. Radiology. 1994;190:665–8.
23. Yammine K. The prevalence of os acromiale: a 40. Kummel BM. Fractures of the glenoid causing
systematic review and meta-analysis. Clin Anat. chronic dislocation of the shoulder. Clin Orthop.
2014;27:610–21. 1970;69:189–91.
24. Imatani RJ. Fractures of the scapula: a review of 53 41. Yu JS, Greenway G, Resnick D. Osteochondral defect
fractures. J Trauma. 1975;15:473–8. of the glenoid fossa: cross-sectional imaging features.
25. Armitage BM, Wijdicks CA, Tarkin IS, Schroder LK, Radiology. 1998;206:35–40.
Marek DJ, Zlowodzki M, et al. Mapping of scapular 42. Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic
fractures with three-dimensional computed tomogra- value of US, MR and MR arthrography in shoulder
phy. J Bone Joint Surg Am. 2009;91:2222–8. instability. Injury. 2013;44(Suppl 3):S26–32.
26. Ogawa K, Yoshida A, Takahashi M, Ui M. Fractures 43. Cicak N, Bilic R, Delimar D. Hill-Sachs lesion in
of the coracoid process. J Bone Joint Surg Br. recurrent shoulder dislocation: sonographic detection.
1997;79:17–9. J Ultrasound Med. 1998;17:557–60.
27. van Oostveen DP, Temmerman OP, Burger BJ, van 44. Zlatkin MB, Sanders TG. Magnetic resonance
Noort A, Robinson M. Glenoid fractures: a review of imaging of the glenoid labrum. Radiol Clin N Am.
pathology, classification, treatment and results. Acta 2013;51:279–97.
Orthop Belg. 2014;80:88–98. 45. Omoumi P, Teixeira P, Lecouvet F, Chung
28. Ideberg R, Grevsten S, Larsson S. Epidemiology of CB. Glenohumeral joint instability. J Magn Reson
scapular fractures. Incidence and classification of 338 Imaging. 2011;33:2–16.
fractures. Acta Orthop Scand. 1995;66:395–7. 46. Shah N, Tung GA. Imaging signs of posterior gle-
29. Harris RD, Harris JH. The prevalence and signifi- nohumeral instability. AJR Am J Roentgenol.
cance of missed scapular fractures in blunt chest 2009;192:730–5.
trauma. AJR Am J Roentgenol. 1988;151:747–50. 47. Arndt JH, Sears AD. Posterior dislocation of the
30. Thompson DA, Flynn TC, Miller PW, Fischer shoulder. AJR Am J Roentgenol. 1965;94:639–45.
RP. The significance of scapular fractures. J Trauma. 48. Cisternino SJ, Rogers LF, Stufflebam BC, Kruglik
1985;25:974–7. GD. The trough line: a radiographic sign of poste-
31. Audigé L, Kellam JF, Lambert S, Madsen JE, Babst rior shoulder dislocation. AJR Am J Roentgenol.
R, Andermahr J, et al. The AO Foundation and 1978;130:951–4.
49. Mok DW, Fogg AJ, Hokan R, Bayley JI. The diagnos- of the remplissage procedure, allograft humeral head
tic value of arthroscopy in glenohumeral instability. J reconstruction, and partial resurfacing arthroplasty. J
Bone Joint Surg Br. 1990;72:698–700. Shoulder Elb Surg. 2012;21:1142–51.
50. Kowalsky MS, Levine WN. Traumatic posterior gle- 57. Roux A, Decroocq L, El Batti S, Bonnevialle N,
nohumeral dislocation: classification, pathoanatomy, Moineau G, Trojani C, et al. Epidemiology of proxi-
diagnosis, and treatment. Orthop Clin North Am. mal humerus fractures managed in a trauma center.
2008;39:519–33. Orthop Traumatol Surg Res. 2012;98:715–9.
51. Saupe N, White LM, Bleakney R, Schweitzer ME, 58. Neer CS II. Displaced proximal humeral fractures.
Recht MP, Jost B, et al. Acute traumatic poste- I. Classification and evaluation. J Bone Joint Surg
rior shoulder dislocation: MR findings. Radiology. Am. 1970;52:1077–89.
2008;248:185–93. 59. Neer CS II. Displaced proximal humeral fractures.
52. Lee RK, Griffith JF, Tong MM, Sharma N, Yung II. Treatment of three-part and four-part displace-
P. Glenoid bone loss: assessment with MR imaging. ment. J Bone Joint Surg Am. 1970;52:1090–103.
Radiology. 2013;267:496–502. 60. Rutten MJ, Jager GJ, de Waal Malefijt MC, Blickman
53. Griffith JF, Yung PS, Antonio GE, Tsang PH, Ahuja JG. Double line sign: a helpful sonographic sign to
AT, Chan KM. CT compared with arthroscopy in detect occult fractures of the proximal humerus. Eur
quantifying glenoid bone loss. AJR Am J Roentgenol. Radiol. 2007;17:762–7.
2007;189:1490–3. 61. Berger PE, Ofstein RA, Jackson DW, Morrison DS,
54. Bhatia S, Frank RM, Ghodadra NS, Hsu AR, Romeo Silvino N, Amador R. MRI demonstration of radio-
AA, Bach BR Jr, et al. The outcomes and surgical graphically occult fractures: what have we been miss-
techniques of the latarjet procedure. Arthroscopy. ing? Radiographics. 1989;9:407–36.
2014;30:227–35. 62. Thanasas C, Kontakis G, Angoules A, Limb D,
55. Kokkalis ZT, Mavrogenis AF, Ballas EG, Giannoudis P. Treatment of proximal humerus frac-
Papanastasiou J, Papagelopoulos PJ. Modified tures with locking plates: a systematic review. J
McLaughlin technique for neglected locked pos- Shoulder Elb Surg. 2009;18:837–44.
terior dislocation of the shoulder. Orthopedics. 63. Bufquin T, Hersan A, Hubert L, Massin P. Reverse
2013;36:e912–6. shoulder arthroplasty for the treatment of three- and
56. Giles JW, Elkinson I, Ferreira LM, Faber KJ, Boons four-part fractures of the proximal humerus in the
H, Litchfield R, et al. Moderate to large engaging Hill- elderly: a prospective review of 43 cases with a short-
Sachs defects: an in vitro biomechanical comparison term follow-up. J Bone Joint Surg Br. 2007;89:516–20.
Imaging Diagnosis of Shoulder
Arthropathy 10
Mingqian Huang and Mark Schweitzer
10.1 Introduction shoulder, this secondary osteoarthritis can be

related to cuff tear or instability.
The shoulder is a quite interesting joint. It is Next, we discuss infections of the shoulder. As
highly mobile and maintains an exquisite balance with any monoarthropathy, we clinicians should
in order to maintain its range of motion. In fact, keep this diagnosis in mind. We also should
two of the most common disorders of the shoul- remember that disordered joints of any disease,
der (adhesive capsulitis and instability) are especially those effected by rheumatoid, are pre-
demonstrative of alterations in the balance. disposed to infections.
Articular disorder also may be the end result of Following this we discuss the interrelation-
this loss of stability regulation. Additionally, ship of rheumatoid of the glenohumeral, acro-
articular disorders may be the presentation of mioclavicular joints with each other and with the
loss of motion. rotator cuff.
Also interesting is that articular disorders of the Perhaps the most interesting of the articular
shoulder are proportionally less common in the disorders of the shoulder are those related to
shoulder than the other major joints. Although crystals. Some of these are overwhelmingly more
various theories have been proposed for this incon- common in the shoulder (HADD), and others
gruence, none of them are terribly satisfying. present with complex and unique imaging
Nonetheless, these disorders are far from appearances, such as the Milwaukee shoulder.
infrequent, and are debilitating, and as mentioned
above can mimic clinically more acute shoulder
disorders. 10.2 Osteoarthritis
In the following pages we discuss arthropa-
thies of the shoulder. We discuss how osteoarthri- 10.2.1 Definition
tis presents on imaging, differently than other
large joints such as knee or hip. Differently, since Osteoarthritis (OA) is the most common form of
secondary osteoarthritis is much common in the arthritis, and it is a leading cause of chronic dis-
ability in the elderly population [1]. More than
half of people over 60 will have symptoms of
M. Huang (*) · M. Schweitzer osteoarthritis.
Department of Radiology, Stony Brook University Altman et al. [2] defined OA as “a heteroge-
Hospital, Stony Brook School of Medicine,
neous group of conditions that lead to joint symp-
Stony Brook, NY, USA
e-mail: Mingqian.Huang@stonybrookmedicine.edu; toms and signs which are associated with
Mark.Schweitzer@stonybrookmedicine.edu defective integrity of articular cartilage, in

212 M. Huang and M. Schweitzer
addition to related changes in the underlying

bone and at the joint margins.” It is important to
recognize the difference between idiopathic (pri-
mary) OA and OA that is related to an underlying
condition (secondary). It is also important to rec-
ognize that it is becoming increasingly accepted
that OA likely represents multiple different dis-
eases with similar imaging appearances.
In terms of OA of the shoulder, primary OA
was historically believed to be rare. However,
Philip and Kattapuram [3] noted that primary OA
on radiographic examination is seen in about 1 in
1000 individuals of advanced age and noted that
the condition “may not be as rare as many observ-
ers have stated.” OA could also occur second-
arily, such as sequelae of chronic rotator cuff
tears, fractures, dislocations, rheumatoid, CPPD
arthropathy, avascular necrosis, or congenital
skeletal variants and deformities [3].
In recent years, shoulder degenerative disease Fig. 10.1 Osteoarthritis. Frontal view of the left shoulder
demonstrates a typical medial osteophyte of the anatomic
is becoming more recognized and at the same neck of proximal left humerus, “beard-like” (black arrow)
time therapeutic options for treatment are with an inferior intra-articular body (white arrow)
increasing, both medically and surgically. Hence,
there is a need to develop systematic, reliable,
and noninvasive means to accurately diagnose In a study by Roger Kerr [4] and colleagues,
shoulder degenerative disease, especially at the they compared cadaveric specimens and patient
early stages. radiographs to establish the pattern and distribu-
tion of degenerative alterations of the glenohu-
meral joint. They found that the most frequent
10.2.2 Radiographic and CT Findings degenerative abnormality was the formation of
osteophytes along the articular margin of the
On radiographs, the findings of primary OA of humeral head at the line of attachment of the
the shoulder are similar to OA findings in large labrum to the glenoid. This is probably due to
joints, elsewhere in the body. Noted are osteo- functional stress provided by capsular traction [5,
phytes, cartilage loss with space narrowing, 6]. However, routine radiographs tend to under-
occasional subchondral sclerosis, and infre- estimate the degree of osteophyte formation
quent cystic changes. Specifically, the marginal involving both the humeral head and the glenoid
osteophytes tend to develop along the anatomic [4]. This underestimation is true for all joints,
neck of the proximal humerus and are nearly however. The second degenerative-like finding in
always more prominent medially, often with a their study is focal or global eburnation of the
“beard-like” appearance (Fig. 10.1). In more articular surface of the humeral head. This is
advanced cases, the humeral head becomes most evident in the middle and superior parts of
pseudo-flattened (due to lateral humeral head the humeral head, consistent with that described
osteophytes) and positioned posteriorly, due to by Neer [7]. They also found that the degree of
the asymmetric joint space loss. There is occa- enthesopathic change generally parallels that of
sional posterior glenoid subchondral cystic osteophyte formation. Such changes consist pre-
changes and even less frequent subchondral dominantly of bony proliferation with occasional
sclerosis. areas of pitting or cystic change, involving the
10 Imaging Diagnosis of Shoulder Arthropathy 213
a b
Fig. 10.2 Advanced osteoarthritis. Axial (a) and sagittal joint-space loss, related subchondral sclerosis, and cystic
(b) reformatted images demonstrate posterior displace- changes at the posterior glenoid (white arrow)
ment of the humeral head over the glenoid (black arrow),
anatomic neck and extending over the tuberosi- sions, osteophyte formation, subchondral cysts,
ties and bicipital groove [4]. A strong association and sclerosis and synovitis in more detail. Central
was found between the changes of OA and those and posterior glenoid wear with sclerosis and
related to deterioration of the rotator cuff [4]. cartilage loss is typically seen in shoulder
This is likely related to epidemiologic overlap in OA. This is better seen on axial proton density
the populations involved. (PD) and FS (fat-suppressed) PD fast spin-echo
With multiplanar capability, CT scan can (FSE) images (Fig. 10.3). Humeral head sclerosis
depict posterior glenoid wear and posterior and cartilage loss are usually central or superior
humeral subluxation (Fig. 10.2) in primary in glenohumeral osteoarthritis. Peripheral osteo-
degenerative joint disease (Fig. 10.2). CT is also phytes projecting from the humeral head are
useful in preoperative planning to assess glenoid directed inferiorly on coronal images. Glenoid
bone stock and degree of posterior bone loss peripheral osteophytes tend to involve the lower
(Fig. 10.2) [8, 9]. two-thirds of the glenohumeral joint. Subchondral
cysts can be seen in both glenoid and humeral
head. The inferior capsule may be enlarged and
10.2.3 MR Findings the anterior capsule contracted. Intra-articular
bodies can frequently be seen in the subscapu-
Radiographic findings of glenohumeral joint laris recess or within the biceps tendon sheath. A
degenerative changes are well recognized, though secondary chondromatosis is associated with
they tend to occur late in the course of the disease full-thickness chondral loss of the humerus or
when therapeutic options are more limited and glenoid. An intraosseous ganglion is a less com-
less effective. MR can provide information on mon finding in degenerative OA.
early pre-structural changes, especially cartilage Imaging of articular cartilage in the shoulder
loss. MR imaging is also superior to plain is challenging for MR imaging due to the deep
radiograph in helping identify other causes that shoulder joint, relatively thin glenoid cartilage,
may cause patient chronic shoulder pain. and difficulty placing the joint isocenter in the
MR imaging with multiplanar capability and imaging system. But improvements have been
soft-tissue resolution depicts the chondral ero- made in contrast and resolution. Progress has
a b
Fig. 10.3 Cartilage loss. Axial (a) and coronal oblique (b) fat-suppressed fluid-sensitive MR images demonstrate car-
tilage loss along the glenoid (black arrow) and humeral head (white arrow) with subchondral marrow edema
been made in understanding cartilage physiol- tion of the T2 relaxation time may reveal areas of
ogy and ability to detect proteoglycan and increased or decreased water content, correlating
collagen loss. with cartilage damage. Sodium MR imaging has
MR is effective at assessing the degree of shown some promising results recently of imag-
damage to cartilage and adjacent bone, and effec- ing articular cartilage. This is based on the ability
tiveness of treatment. Arthroscopy is invasive, of sodium imaging to depict regions of proteo-
but the gold standard for monitoring cartilage glycan depletion [15]. Another innovative
damage in shoulder with optical resolution and physiologic imaging alternative is spin-lattice

ability to probe the cartilage surface. With the relaxation in the rotating (T1 rho). This technique
advancement of technology, more MR sequences exploits the low-frequency interactions between
have been developed to enable better evaluation macromolecules and bulk water and has been
of the glenoid cartilage. Cartilage volumes in the applied to articular cartilage [16]. Ultrashort TE
shoulder can be measured using 3D spoiled imaging has also demonstrated good delineation
gradient-echo 3D-SPGR [10]. However, there are of cartilage lesions [17].
two main disadvantages of limited contrast
between cartilages and fluid that outlines the sur-
face defects and long scanning time. Steady-state 10.2.4 Ultrasound Findings
free precession (SSFP) MR imaging has shown
to be a promising method for cartilage imaging in In shoulder osteoarthritis, the progressive disinte-
the knee [11, 12]. gration of the articular surfaces leads to the for-
Advanced MR imaging of articular cartilage mation and release of intra-articular loose bodies
composition takes advantage of the fact that which, once freed into the joint cavity, can pro-
articular cartilage is approximately 70% water gressively worsen the damage to the joint sur-
and rest are type II collagen fibers and proteogly- faces. Osteochondral bodies usually remain
cans. Gadolinium-enhanced imaging has the trapped in the most dependent portions of the
potential to allow monitoring of glycosaminogly- glenohumeral joint, such as the axillary pouch
can content within the cartilage [13, 14] and thus and the long head of the biceps tendon sheath.
monitoring physiologic state of the cartilage Most of the intra-articular bodies appear as
repair. T2 mapping of T2 relaxation time of artic- hyperechoic areas with posterior acoustic shad-
ular cartilage is a function of the water content of owing. In some cases, however, a thin layer of
the tissue. Measurement of the spatial distribu- hypoechoic cartilage may be seen overlying the
echogenic interface of the subchondral bone [18]. Patients often present with complaints of chronic,
The size and position of a fragment can be reli- progressive shoulder pain that is worse at night
ably evaluated with US, but the exact number of and with use of shoulder.
fragments cannot always be established.
10.3.2 Radiographic and CT Findings

10.3 Rotator Cuff Arthropathy
Glenohumeral joint degenerative changes, osteo-
10.3.1 Definition penia of the humeral head, and superior migra-
tion of the humeral head are the common findings.
Cuff deficient arthritis of the glenohumeral joint Humeral migration leads to changes in the acro-
encompasses a number of pathologies including mion, acromioclavicular joint, coracoid, and gle-
osteoarthritis without a competent rotator cuff, noid. Abnormal contact between the humerus
rheumatoid arthritis, degenerative joint disease and the acromion can lead to rounding off of the
secondary to failed rotator cuff repair, and cuff greater tuberosity (femoralization) and concave
tear arthropathy (CTA). erosion of the undersurface of the acromion (ace-
Robert Adams first described the clinical tabularization) [26, 27]. Superior glenoid erosion
findings of CTA in 1857. Charles Neer [19] is another common sequela of superior humeral
coined the term “cuff tear arthropathy” in 1977 head migration.
and went on to provide the first detailed descrip- Migration results in a decreased acromiohum-
tion in 1983. It is characterized by a rotator cuff eral interval (AHI) on anteroposterior (AP) radio-
tear, proximal migration of the humerus with graphs, which is the distance from the
femoralization of the humeral head and acetab- undersurface of the acromion to the superior
ularization of the acromion, glenoid erosion, aspect of the humeral head. Hamada et al. [28]
loss of glenohumeral articular cartilage, osteo- used the AHI on AP radiographs as the basis for
porosis of the humeral head, and eventually radiographic classification system of massive
humeral head collapse. Neer et al. [19] esti- rotator cuff tears. In grade 1, the AHI is greater
mated that only 4% of patients with a complete than 6 mm; in grade 2, the AHI is 5 mm or less.
tear of the rotator cuff go on to develop CTA In grade 3, there is acetabularization of the
based on their experience over the 8-year period acromion in addition to the findings of grade 2. In
from 1975 to 1983. grade 4, there is glenohumeral joint space nar-
There were debates over the years about the rowing in addition to the findings of grade 3. In
pathophysiology of CTA. Especially since grade 5, there is humeral head collapse.
“Milwaukee shoulder,” this was considered by The massive loss of the rotator cuff and the
Neer as the same condition as CTA initially. And associated superior humeral migration lead to
the etiology of this condition is considered to be destabilization of the glenohumeral center of
under the hydroxyapatite crystal-mediated the- rotation. The amount of decentralization depends
ory. In 1997, Collins and Harryman [20] synthe- on the extent of the rotator cuff tear, the integrity
sized Neer’s theory on CTA pathogenesis with of the coracoacromial (C-A) arch, and the degree
the crystal-mediated theory. Superior humeral and direction of the glenoid bone erosion.
migration that results from the loss of rotator cuff Analysis of cuff tear arthropathy and failed treat-
dynamic stability leads to abnormal trauma of the ments has led to a biomechanical classification of
glenohumeral articular cartilage and the cora- cuff tear arthropathy by Seebauer [26]. Four dis-
coacromial arch. This trauma releases particulate tinct groups have been formed on the basis of the
debris into the joint, setting off the crystal- biomechanics and clinical outcomes of arthro-
mediated inflammatory cascade. plasty. The four types are distinguished by the
CTA tends to afflict the elderly, with women degree of superior migration from the center of
more likely to be affected than men [21–25]. rotation and the amount of instability of the
center of rotation. This classification was pro- in type E3 the erosion extended to the inferior
posed for benefits in surgical decision-making part of the glenoid.
for optimal implant type, goals of reconstruction, The geyser phenomenon that soft-tissue mass
and outcomes. is superior to the acromioclavicular joint is a
well-recognized finding related to underlying
• Type 1A: centered stable, minimal superior rotator cuff tear.
migration, C-A arch acetabularization CT can provide a more detailed view of the
• Type 1B: centered medialized, minimal supe- bony architecture that can be used for determin-
rior migration, medial glenoid erosion, C-A ing the extent of the bone erosion when planning
arch acetabularization treatment.
• Type 2A: decentered limited stable, superior
translation, superior-medial erosion, signifi-
cant C-A arch acetabularization. 10.3.3 MRI Findings
• Type 2B: decentered unstable, anterior supe-
rior escape, C-A arch and anterior structures MRI provides detailed information of the soft-
deficient. tissue structures of the shoulder (Fig. 10.4), such
as the extent of the rotator cuff tear, the location
Based upon the preoperative radiological of the tear, and the quality of the rotator cuff mus-
appearance, four types of glenoid erosion were cles and tendons.
defined by Sirveaux [29]. In type E0, the head of Saupe et al. [30] showed that the size of rota-
the humerus migrated upwards without erosion tor cuff tendon tears and the extent of fatty infil-
of the glenoid. Type E1 was defined by a concentration of the rotator cuff muscles have a
tric erosion of the glenoid. In type E2 there was significant negative correlation with the AHI
an erosion of the superior part of the glenoid and (p < 0.05).
a b
Fig. 10.4 Rotator cuff arthropathy with early geyser phe- with superior migration of the humeral head and narrowing
nomenon. Coronal oblique (a) and sagittal oblique (b) fat- of the acromiohumeral space. Fluid is noted extending supe-
suppressed fluid-sensitive sequences of the shoulder. Note is rior through the acromioclavicular joint superior, delineat-
made of the full-thickness supraspinatus tear (white arrow) ing an early geyser formation (black arrows)
10.3.4 Ultrasound Findings bones. Diaphyseal vessels in the newborn traverse

the physis, allowing hematogenous agents ready
Superior humeral migration can be seen at coro- access to the epiphysis and joint. Beginning at
nal ultrasound as a reduced acromiohumeral dis- approximately 8–18 months of age, the diaphyseal
tance. The humeral head shows loss of the vessels instead terminate in sinusoidal lakes situ-
hypoechoic layer of articular cartilage and bone ated in the metaphysis, effectively obliterating any
irregularities; the greater tuberosity has a smooth hematogenous pathway to the epiphysis. This
appearance and blends with the humeral epiphy- accounts for the metaphyseal predilection of infec-
sis. In these circumstances, it might be hard to tions such as Brodie abscesses in adolescence.
identify the bicipital groove. Reduced thickness After the closure of the growth plate in adulthood,
of the acromion may be seen. infection can more easily extend to the epiphysis
Superior humeral migration can lead to sec- and joint [36]. Even in the neonatal age group,
ondary damage of the inferior acromioclavicular incidentally, the knee and hip are much more com-
joint capsule and passage of joint fluid through mon sites of infection than is the shoulder.
the acromioclavicular joint, producing a cyst in The potential sources for shoulder joint infec-
the soft tissue at the superior aspect of the shoul- tion include (1) hematogenous spread either sec-
der (“geyser sign”), and a finding that may be ondary to hematogenous seeding of the synovial
considered pathognomonic for long-standing membrane from a distant focus or spread from an
massive rotator cuff tears. During passive move- adjacent epiphyseal area of osteomyelitis by
ments of the arm or exertion of pressure on the means of vascular continuity between the epiphy-
cyst with the probe, debris may be seen moving sis and the synovial membrane; (2) spread from a
to and fro across the acromioclavicular joint. contiguous source of infection (e.g., such as in the
diabetic foot); (3) direct implantation; and (4)
postprocedural implantation often following local
10.4 Septic Arthritis corticosteroid injection [37]. Following joint injec-
tions, the incidence of septic arthritis is approxi-
10.4.1 Definition mately 1/1000. The complexity and increasing
performance of orthopedic procedures, including
Septic arthritis of the shoulder is rare. Recent arthroscopy and joint replacement, have resulted
reviews from both Europe and the United States in an increase in postoperative shoulder infections.
have reported a similar low incidence, with 21, It has been suggested that the infection rate follow-
17, and 23 cases over 8-, 11-, 15-year periods, ing total shoulder joint arthroplasty is around 2%
respectively [31–33]. Most cases of septic arthri- for constrained systems, and of less than 1% for
tis tend to occur in patients with underlying artic- unconstrained systems or for humeral prosthetic
ular disease. Septic arthritis of the shoulder rarely placement alone [38, 39]. Infection may occur in
develops in young adults or in healthy individuals the early postoperative period, or after months and
of any age [34]. In the series of Leslie et al. [34] years following the initial surgery.
and Pfeiffenberger et al. [35], the average age of Staphylococcus aureus and Neisseria gonor-
patients suffering from septic arthritis of the rhoeae are examples of bacteria that have a high
shoulder was 65 years and 61 years, respectively. degree of selectivity for the synovium, probably
Although the overall incidence is low, there is an related to their adherence characteristics and
apparent increase of septic shoulder arthritis. This toxin production [34, 35, 39]. Thus, the most
is possibly due to increased aging of the general common causative organism in all age groups
population and hence more frequent underlying, combined for shoulder septic arthritis is
predisposing shoulder articular disease. Staphylococcus aureus [40–42]. Group D
Septic arthritis is rare between late infancy and streptococcus is an important cause of septic

young adulthood. This is thought to be related to arthritis in neonates and infants, whereas
the evolution of vascularity within developing Haemophilus influenzae and Staphylococcus
aureus are important causes, respectively, in In general, there are no reliable clinical signs for
young children and adults, the former only in septic arthritis at clinical examinations, and the
those without immunization [37]. lack of a visible inflammatory response should
In recent years, an increasing number of not exclude the diagnosis of a septic shoulder. In
Staphylococcus aureus infections have been a series of Leslie et al. [34], in one-third of the
attributable to methicillin-resistant S. aureus patients with shoulder septic arthritis the diagno-
(MRSA) strains. In Cleeman and colleagues’ sis had been delayed more than 6 months.
series of 23 cases of glenohumeral infections, for Leukocytosis and positive blood and joint
instance, 70% of cases were due to S. aureus and cultures are important laboratory parameters of
of these 17% were MRSA [33]. pyogenic arthritis [44, 45]. However, leukocyto-
Multifocal septic arthritis in young adults is sis is an unreliable indicator, as it may be absent
suggestive of gonococcal arthritis. Certain patient in immunocompromised patients. Increased
populations are more susceptible to specific bacte- C-reactive protein levels and erythrocyte sedi-
ria. Patients with sickle cell anemia are more prone mentation rates may be present. However, they
to Salmonella infection, although this remains less are not very specific, since elevated levels can
frequent in these patients than staph infections. also be seen in other inflammatory conditions
Septic arthritis caused by Mycobacterium tubercu- such as rheumatoid arthritis.
losis is rare [34]; however, with the increasing Because of the devastating sequelae of septic
number of immunocompromised patients (AIDS, arthritis, any monoarticular arthritis should be
immunosuppressive therapy), tuberculous involve- regarded as infection until proven otherwise.
ment of the shoulder is becoming more frequent. Increasing number of septic arthritis is occurring
Despite the above tendency, staphylococcus is still due to the increasing immunocompromised pop-
the most common causative organism in nearly all ulation and microorganisms that are resistant to
patient populations. common drugs [46]. It is imperative for clinicians
Degenerative joint disease, rheumatoid arthri- and radiologists to provide a prompt and accurate
tis, and corticosteroid therapy are the most com- diagnosis. Septic arthritis is ultimately a clinical
mon predisposing conditions for shoulder septic diagnosis that hinges on appropriate synovial
arthritis. In particular, patients with severe rheu- fluid analysis. Direct sampling of joint fluid
matoid arthritis with significant functional impair- remains as the most important diagnostic step.
ments are at greater risk of septic arthritis as a
complication of the disease [43]. Patients with dia-
betes mellitus, leukemia, liver cirrhosis, cancer, 10.4.2 Radiographic and CT Findings
hypogammaglobulinemia, and intravenous drug
abuse have also an increased incidence of septic Radiographs usually are the first-line imaging
arthritis [34]. AIDS patients and stem cell recipi- modality used in patients with suspected shoul-
ents are illustrative examples of hosts with der septic arthritis. Unfortunately, initially, radio-
impaired immune responses and susceptible to graphs can be normal, which does not exclude
infections caused by uncommon microorganisms. infection. Initial radiographs can also be used to
There is no specific presentation or physical determine associated conditions, such as osteoar-
examination sign for septic arthritis. There is thritis and inflammatory arthropathy, or may be
considerable clinical and imaging overlap with used as a baseline image in monitoring the
any inflammatory arthropathy. An acute onset response of treatment.
with fever and chills is common. Pain, tender- The first detectable abnormalities are soft-
ness, redness, heat, and soft-tissue swelling about tissue swelling with hyperemia and joint
the involved joint are the usual complaints and distention secondary to effusion. However, both
findings. However, there is considerable variation of these imaging findings tend to be occult on
in the presentation depending on the causative shoulder radiography. The hyperemia can result
bacterial agent, the patient’s immune status, and in osteopenia on radiographs and followed by
the presence of preexisting joint abnormality. uniform joint space narrowing and erosions
u sually at the joint margins. Advanced cases of Thick and/or frond-like rim-enhancing
infection are associated with subluxation or dis- synovium on postcontrast fat-suppressed
location and massive bone destruction. During T1-weighted images are typical findings of syno-
recovery, bones recalcify and although marginal vial inflammation in septic arthritis. Because the
erosions do not disappear such erosions become synovium normally enhances with gadolinium,
well demarcated and sclerotic. In severe cases, careful examination of intensity of the enhance-
fibrous or bony ankylosis may occur. ment, as well as the character of the synovium,
Arthrography in the evaluation of joint infection should be performed. Comparison with other vis-
should be used only in conjunction with joint aspi- ible synovial structures should be performed. On
ration to obtain fluid for bacteriologic examination. postcontrast images, the acromioclavicular joint
Injection of contrast material into the joint should can be used as a standard of reference for normal
be performed only after fluid aspiration due to the enhancement in the absence of complete commu-
bacteriostatic properties of contrast agents. nicating rotator cuff tears.
Radiographs obtained after injection of contrast In the normal glenohumeral joint, almost no
material may reveal destruction of the articular car- fluid is present. In a review of 20 shoulder MR
tilage and hypertrophic alterations in the synovium. imaging studies of 12 asymptomatic patients,
In chronic septic arthritis, arthrography may dis- Recht and colleagues [50] found joint fluid in 14
play an irregular or contracted joint capsule [47]. shoulders, but not exceeding 2 mL in any cases.
Complications of septic arthritis are sublux- MR imaging can provide an assessment of the
ation and dislocation, osteonecrosis, fibrous or fluid volume in the joint. The following criteria
bony ankylosis, chronic degenerative arthritis, have been proposed: grade 0 reflects scant fluid
and bone growth disturbance (lengthening, short- not distending any joint recesses; grade 1 demon-
ening, and angulation) [37]. strates a small amount of fluid in the subscapu-
Radiographs lack specificity in demonstrating laris recess, axillary recess (marked by a
nonpyogenic infection of the shoulder, especially U-shaped inferior capsule), or biceps tendon
tuberculosis (TB). The cardinal features of myco- sheath on at least two coronal-oblique images;
bacterial infection are osteoporosis, marginal grade 2 demonstrates distention of at least two of
subchondral erosions (usually occurring later), these recesses; and grade 3 demonstrates fluid in
and gradual and delayed cartilage destruction: all three recesses [51]. The effusion tends to be
the triad of Phemister [48]. An appearance simi- homogenous, although loculation and inhomoge-
lar to chronic pyogenic osteomyelitis can be seen, neity may be seen in more chronic septic process
including sclerosis, periostitis, and synovial [37]. The effusions of glenohumeral septic arthri-
membrane thickening [49]. tis frequently dissect into the subscapularis
On CT images, joint effusion, synovial thick- recess. From there, they frequently lead to syno-
ening, and soft-tissue swellings are early mani- vial outpouching into the muscles of the rotator
festations of septic arthritis. Later on, destruction cuff. Rotator cuff tears often occur with subacute
of the articular cartilage, irregularity and narrow- infections, and in this case the infection often
ing of joint, articular erosion, and subchondral spreads to the acromioclavicular joint.
bone destruction can be seen. Bone marrow edema is common. Reactive bone
marrow edema, in the absence of osteomyelitis,
may be present in up to 50% of patients [37]. This
10.4.3 MR Findings reactive edema tends to involve both sides of the
articulation, and be subtle on T1-weighted images.
Synovial inflammation and joint effusion are the The edema pattern is patchy and ill defined. When
earliest signs in septic arthritis and can be easily the marrow edema is quite obvious on T1-weighting
identified on MR imaging. With chronicity the images consider concomitant osteomyelitis. Bone
synovium thickens, the fluid becomes more erosions and cartilage destruction in more advanced
complex, and joint recess becomes increasingly cases are well demonstrated with MR imaging.
distended. Using animal experiments, Bremell et al. [52] have
shown that cartilage loss and subchondral bone d ifferentiation by MR of reactive marrow edema
erosions may develop within days. With protracted changes from osteomyelitis is often challenging,
subchondral loss, the infection may progress to because both can show edematous-enhancing
subacute phase, when subchondral marrow edema marrow changes. There tends to be more overt
and subchondral cyst formation occur. and confluent marrow changes on T1-weighted
In the chronic stages of glenohumeral septic images in patients with osteomyelitis.
arthritis, joint destruction will ultimately lead to Overall, synovial enhancement, peri-synovial
ankylosis. Osteomyelitis may occur and the edema, and joint effusion (Fig. 10.5) are the MR
a b
c d
Fig. 10.5 56-Year-old patient with septic glenohumeral mial subdeltoid bursa and periarticular soft-tissue
arthritis and history of recent discitis and osteomyelitis enhancement. Fat-suppressed proton density axial image
of the lumbar spine. Axial fat-suppressed proton density (a) and precontrast (c) demonstrates surrounding deep
(a), coronal oblique postcontrast (b), axial fat-sup- soft-tissue edema (black arrows). Coronal oblique post-
pressed T1 precontrast (c), and axial postcontrast MR contrast image (d) demonstrates additional peripheral
images demonstrate thick synovial enhancement (black enhancing small collections in the subscapularis muscle
arrows) of the glenohumeral joint effusion and subacro- (white arrows)
findings that correlate most with septic arthritis. echo images after iron nanoparticle infection is
Karchevsky and colleagues [53] reported the correlated with the number of USPIO-loaded
presence of these findings in 98, 84, and 70%, cells [60, 61]. Lefevre S and colleagues [62]
respectively, of 50 consecutive subjects with joint using USPIO-enhanced macrophage MR tech-
infection (the study was not restricted to glenohu- nique imaged rabbits with knee septic arthritis in
meral infection). acute phase of infection and after antibiotic treat-
In everyday practice, differentiation of septic ment and compared with histological specimen
arthritis of the shoulder versus nonseptic and gadoterate dimeglumine-enhanced fat-
inflamed joint is very difficult. Graif et al. [54] suppressed T1-weighted MR images. They con-
have shown that no single MR sign, including cluded that USPIO-enhanced macrophage MR
joint effusion, fluid outpouching, fluid heteroge- can demonstrate resolution of experimental bac-
neity, synovial thickening, peri-synovial edema, terial joint infection.
synovial enhancement, cartilage loss, bone ero- It is important to be mindful of nonpyogenic
sions, bone erosion enhancement, bone marrow infections when evaluating for shoulder septic
edema with and without enhancement, soft-tis- arthritis, especially those caused by
sue edema with and without enhancement, and Mycobacterium tuberculosis and other myco-
periosteal edema, reliably distinguishes between bacteria, for they can present with quite different
the two entities. The combination of bone ero- clinical and imaging pictures. Skeletal TB is
sions with marrow edema is highly suggestive of encountered in 1–3% of extrapulmonary cases of
septic arthritis; however joint aspiration is TB, and of these skeletal cases 1–10% involve
required for confirmation. the shoulder [49]. Nonpyogenic infection can
With high spatial resolution and soft-tissue smolder in the joint for years. Richter and col-
contrast, MRI is our current best clinical imaging leagues [63] found an average 15-month delay
tool at monitoring treatment and disease progres- from time of symptom onset to correct diagnosis
sion in patients with septic arthritis. Bierry G and of TB of the shoulder. Periostitis and synovial
colleagues [55] reported their findings after com- membrane thickening are features that can be
paring patients MRI before and after surgical demonstrated on MR imaging. Large effusion
debridement and antibiotic treatment and correla- and osteolysis are other associated features.
tion with microbiological and clinical data. They T2-intermediate intraosseous tubercles are
found that the sizes of joint effusions and sometimes encountered.
abscesses both decreased following successful Tuberculous bursitis has been well described,
treatment. However, synovial thickening and most commonly in the bursae of the shoulder,
enhancement, periarticular myositis/cellulitis, hands, ischium, and gluteal muscles [48]. TB
and bone marrow edema can persist even after often has a predisposition to the subacromial/
resolution of the infection. subdeltoid bursa. Intrabursal rice bodies can be
Macrophage MR imaging with sequences seen in TB, or any kind of chronic bursitis,
enhanced with ultrasmall superparamagnetic iron appearing to be no more than several millimeters
oxide (USPIO) particles has been widely investi- in size and isointense to muscle on both
gated and has demonstrated its ability to help T1-weighted and T2-weighted images [64].
demonstrate joint inflammation or infection [56, These bodies can often calcify and show signal
57]. USPIO particles undergo macrophage voids as well as bloom on gradient-echo images.
phagocytosis with persistent T2 or T2* effects on In advanced stages of nonpyogenic infection,
delayed postcontrast MR images in tissues with there are significant bone and joint destructions
macrophage infiltration [58]. Macrophages are similar to pyogenic septic arthritis.
recruited in infected joints in the early phases of In patients with a history of shoulder arthro-
infection and decrease with infection resolution plasty or with metallic implants, artifacts from
[59]. It has recently been shown that the number the metallic prostheses and radiopaque cement
of dark pixels observed on T2-weighted gradient- pose big challenges for detection of underlying
septic arthritis. Field distortion can be minimized effusion is gravity dependent so the probe must
by using lower field strength scanners, wider be walked up to the musculotendinous junction.
bandwidths, smaller voxels, and/or higher gradi- When there is joint effusion, usually the biceps
ents. Frequency-selective fat suppression and tendon can be seen completely surrounded by
gradient-echo sequences should be avoided. fluid. Posteriorly, the effusion will displace the
STIR and water excitation can be used instead for capsule and the infraspinatus tendon. In one
less distortion. Recent advancement in MR imag- review of 30 glenohumeral joint effusions, fluid
ing technology has also enabled better results in was consistently identified by US in the posterior
this area. Fast spin-echo (FSE) metal artifact joint recess in 100% of the patients and in the
reduction sequences (MARS), and newer multi- biceps tendon sheath in 97% [71].
acquisition variable-resonance image combina-
tion (MAVRIC) and slice-encoding metal artifact
reduction (SEMAC) sequences, are among the 10.5 Rheumatoid Arthritis
new developments. Initial studies on patients
undergoing shoulder, hip, and knee arthroplasty 10.5.1 Definition
have demonstrated improved visualization of
synovitis, periprosthetic bone, supraspinatus ten- Rheumatoid arthritis (RA) is a chronic systemic
don fibers, and supraspinatus tendon tears with disorder that can lead to significant disability,
MAVRIC sequences [65–67]. morbidity, and even decreased life expectancy
[72]. RA affects 1–3% of the adult population in
Europe and the United States [73]. RA is the
10.4.4 US Findings most common type of inflammatory arthritis
treated by rheumatologists and comprises up to
Ultrasonography has a growing role in the evalu- 25% of all referrals to rheumatology clinics and
ation of septic arthritis of the shoulder. The main 75% of follow-up work [74]. The peak onset is
ultrasound findings are superior bulging of the between fourth and sixth decades of life. Women
joint capsule, widening of the joint space with are two to three times more likely to be affected
erosion of the bony edges, and debris moving by RA than men [75].
freely within the joint space (new [68]). RA is a chronic inflammatory process that
Both joint effusion and synovial hypertrophy characteristically targets the synovial lining of
can be well depicted on US. Synovial hypertro- diarthrodial joints. As the disease progresses,
phy usually appears as hypoechoic intra-articular destruction of the structural components of the
material that lacks compressibility and mobility joints follows. As a systemic disorder RA is also
and often demonstrates flow on Doppler images frequently associated with a variety of extra-
[69]. Septic effusions may be completely articular manifestations.
anechoic or associated with septations and debris. The pathogenesis of RA is multifactorial
However, neither the size nor the relative echo- including genetic, immunoregulatory, and envi-
genicity of the fluid can be used to distinguish an ronmental factors [76]. One of the few voluntary
infected inflammatory effusion from an unin- risk factors is heavy cigarette smoking. Among
fected inflammatory effusion [70]. Although US the newer advances in this area is an association
is unable to confirm the diagnosis of septic arthri- between major histocompatibility complex, class
tis, it may be effective in guiding needle aspira- II, DR beta 1 (HLA-DRB1), and disease severity
tion of the joint. [77]. The HLA-DRB1 gene provides instructions
There are two different locations where effu- for making a protein that plays a critical role in
sions can be easily seen of the shoulder: the the immune system and is part of a family of
bicipital groove and the posterior joint recess. genes called the human leukocyte antigen (HLA)
The bicipital groove is best seen by the anterior complex. The HLA complex helps the immune
view, looking for the long biceps tendon. The system distinguish the body’s own proteins from
proteins made by foreign invaders such as viruses involved large joints in RA, and RA is the most
and bacteria. Several studies have implicated the common inflammatory arthropathy to involve
oral cavity bacterium Porphyromonas gingivalis the shoulder. Shoulder involvement can be seen
in the pathogenesis of the disease, noting that RA in 70% of patients with RA. However, the shoul-
patients have high antibodies to the organism der joint becomes involved later than other upper
[78]. It is thought that the bacterium’s ability to limb joints in RA patients. During the first
citrullinate enolase molecules at a site slightly 2 years of the disease, nearly 50% of patients
different from that which is citrullinated physio- suffer from shoulder symptoms, and during the
logically may produce the autoantigen central to first 14 years 83% of patients have similar shoul-
the inception of RA. Anticitrullinated protein der complaints [83].
antibodies (ACPAs) have been found in the serum RA of the shoulder frequently involves both
of RA patients and are thus considered a funda- glenohumeral and acromioclavicular (AC) joints.
mental part of the disease pathway [79]. In a study of 148 shoulders at 15 years of follow-
Autoantibodies (rheumatoid factor and ACPA) up, Lehtinen and colleagues [84] found erosive
result in synovial inflammation, pannus forma- change in the acromioclavicular joint alone in
tion, and bone and cartilage destruction with sys- 17% of the shoulders, in the glenohumeral joint
temic manifestations. alone in 6%, and in both joints in 42%. The bur-
Autoimmune factors are well-recognized sae surrounding the shoulder, particularly the
components in the pathogenesis of RA. Native B subacromial subdeltoid bursa, are also commonly
cells accumulate in synovium where select clones involved. This could present clinically as mass-
are continuously activated [78]. Synovial tissue T like lesion and may be mistaken for a soft-tissue
cells that express transcription factors are also neoplasm.
important for maintaining the inflammatory In patients with inflammatory arthritis, the
response. The synovium, congested with immune pain may limit the use of the affected shoulder. If
cells, becomes progressively inflamed under the no appropriate physical therapy is conducted, the
influence of monocyte and macrophage-secreted joint capsule and ligaments may shorten and
cytokines such as interleukins (IL)-1, IL-6, and result in adhesive capsulitis/“frozen shoulder.”
IL-17, and tumor necrosis factor alpha (TNFα) The joint contracture leads to greater pain and
[78, 80, 81]. These cytokines can cause synovial even less motion, and eventually substantial atro-
neovascularization and cartilage damage. phy of the rotator cuff musculature [85]. With the
Recent studies have emphasized the impor- progression of this atrophy, the humeral head
tance of fibroblast-like synoviocytes (FLSs) that becomes superiorly migrated which causes
predominate in the synovium of RA patients, in impingement of the rotator cuff between the
the spread of RA from one joint to the other [82]. humerus and acromion, predisposing to tear.
RA can involve any synovial joints in either Additional cytokines in both the inflamed bursa
the peripheral or the axial skeleton. However, and joint lead to collagen breakdown in the rota-
there is a preference for the metacarpophalangeal tor cuff. Up to 80% of RA patients have signifi-
(MCP), metatarsophalangeal (MTP), and proxi- cant thinning of the rotator cuff, and up to 20%
mal interphalangeal (PIP) joints of the hands and have full-thickness tears [85, 86]. This thinning
feet, the distal radioulnar joint, and radiocarpal of the cuff may easily be confused with a cuff
joints. tear, and special care should be paid in the inter-
Swelling of the PIP joints is one of the most pretation of these images. Although cuff repair is
common early clinical signs. The severity of the an option, benefits are limited. One review over a
shoulder joint involvement is related to the gen- 15-year period demonstrated significant improve-
eral severity of the disease. Sparing of the distal ments in pain and patient satisfaction after repair,
interphalangeal joint is a useful sign to distin- but functional gains (defined as an increased rage
guish it from osteoarthritis or psoriatic arthritis. of abduction) were only obtained in the partial-
The shoulder joint is one of the most commonly thickness tear group [87].
10.5.2 Radiographic and CT Findings tomic neck, the greater tuberosity, and the glenoid
cavity. At the end, the destruction pattern may
Radiography has for a long time been the stan- mimic a neuropathic joint or severe crystal depo-
dard for assessing joint damages in RA. The ear- sition disease, such as Milwaukee shoulder.
liest finding on radiographs is periarticular Upward migration index (UMI) evaluates
osteoporosis, followed by erosions and subchon- proximal humeral migration which is secondary
dral cysts at the articular margins of the humeral to rotator cuff tear and fatty atrophy of the rotator
head, followed later by central or peripheral gle- cuff muscles. This is measured by a ratio of the
noid erosions [88]. Glenohumeral joint space distance from center of humeral head to acro-
narrowing is a late finding in RA, and this slower mion (CA) to radius of humeral head, as
progression of cartilage destruction by synovial UMI = CA/R. An UMI >1 0.35 indicates normal
pannus may be related to either the absence of rotator cuff and UMI <1.25 indicates severe
weight bearing or the relatively high cartilage-to- proximal migration of humeral head and rotator
synovial ratio [84]. Erosion in shoulder is most cuff tear. Van der Zwaal et al. [89] studied 44
prominent along the superolateral portion of the shoulders over an 8-year period of time. They
humerus, adjacent to the greater tuberosity demonstrated that a plain anteroposterior radio-
(Fig. 10.6). This is the bare area between the graph of the shoulder is sufficient to assess any
articular cartilage of the humeral head and the progression of rheumatoid disease and to predict
reflection of the joint capsule. Deep, bony ero- functional outcome in the long term by using the
sion may also develop at an opposite side, at the UMI as an indicator of rotator cuff degeneration.
medial aspect of the surgical neck of the humerus, Widening of the acromioclavicular joint
related to pressure exerted by the glenoid margin. space with inferior clavicular erosions and sec-
Rarely, these large erosions can result in a patho- ondary osteoarthritic changes are the common
logic fracture of the humeral neck. Continued manifestations of AC joint involvement. In a
destruction can lead to extension of bony ero- series of 49 patients with RA, Petersson [90]
sions, resulting in destruction of the entire ana- assessed clinical and radiographic findings and
noted radiographic changes to the acromiocla-
vicular joint in 85% of cases.
Radiography can assess the joint damage at
the onset of RA and document the progression
and response to treatment during the course of
the disease. The benefits of radiography are low
costs, high availability, and possibility of stan-
dardization and blinded centralized reading, rea-
sonable reproducibility, and existence of
validated assessment methods [91]. Thus, radi-
ography findings are part of the American
College of Rheumatology (ACR) classification
criteria for RA [92], and is recommended as
obligatory in clinical trials with a duration of
1 year [93].
There are have been several proposed radio-
logical classification systems for shoulder
involvement in RA and each emphasized on dif-
ferent aspects of the disease.
Fig. 10.6 47-Year-old patient with RA. Frontal radio-
graph demonstrates the erosion at the humeral head at the The Larsen classification was proposed in
typical location of bare area (black arrow) 1977 [94] to introduce standard reference films
for RA evaluation in the joints and numerical were distinguished by sphericity of the humeral
scores for each individually involved joint. head and upward migration of the head in rela-
tion to the glenoid. There is similarity of these
• Grade 0: Normal conditions, abnormalities three patterns with the three categories described
not related to arthritis may be present. by Neer. They found that the three patterns do not
• Grade 1: Slight abnormality, periarticular soft- have the same functional prognosis after inser-
tissue swelling, osteoporosis, or joint-space tion of prosthesis.
narrowing.
• Grade 2: Definite early abnormality, erosion, 1. Ascending pattern: Most frequent, upward
and joint-space narrowing present, erosion migration of humeral head with retained sphe-
obligatory except in weight-bearing joint. ricity, head initially ascends and then medial-
• Grade 3: Medium destructive abnormality, izes, inferior glenoid notches the humeral
erosion, and joint-space narrowing present, neck at late stage.
erosion obligatory in all joints. 2. Center pattern: No upward migration, uniform
• Grade 4: Severe destructive abnormality, ero- glenoid wear, humeral head pushes into
sion, and joint-space narrowing present, bone glenoid, and progressive head medialization
deformation in weight-bearing joints. with eventual reduction of the acromio-
• Grade 5: Mutilating abnormality, gross bony humeral distance.
destruction, dislocation, and ankylosis. 3. Destructive pattern: Destruction of the
humeral head with loss of sphericity and
The Laine [95] classification from 1954 has notching of the humeral neck and simultane-
three stages based on clinical and radiographic ous glenoid destruction.
findings:
Levigne and Franceschi further classified
• Stage I is slight limitation of shoulder motion, humeral head and glenoid wear in RA in the same
with mild-to-moderate pain and tenderness to paper. For humeral head wear, stage 1: subchon-
palpation. Crepitation may be appreciated on dral bone intact; stage 2: anatomical neck deformed
range of motion. Radiographs show only gen- by notch >10 mm; and stage 3: loss of spherical
eralized osteopenia. form of the head. For glenoid wear, stage 1: sub-
• Stage II is characterized by moderate limita- chondral bone intact or minimally deformed; stage
tion of shoulder motion, moderate-to-severe 2: erosion reaching the base of coracoid; and stage
pain, and crepitus. Radiographic findings 3: erosion going beyond the base of coracoid.
include osteoporosis, erosive bony changes, Computed tomography (CT) may be indicated
and joint-space narrowing. when preoperative analysis of humeral head defects
• Stage III is where severe functional deficits and glenoid articular erosions is necessary [88].
are present; range of motion is painful and Albertson et al. reported agreement between preop-
limits activities of daily living. Radiographs erative CT results and intraoperative findings, con-
show advanced erosive changes of the humeral cluding that CT could characterize osseous defects
head and glenoid. and bone loss more accurately than standard radi-
ography. This is particularly important in evaluat-
Neer [96] later classified RA of the shoulder ing glenoid erosion to determine whether
into three categories based on clinical and radio- implantation of a glenoid component is possible.
graphic findings; his dry, wet, and resorptive As the current therapeutic goal is to minimize
stages are approximately equivalent to those of joint destruction so as to obviate salvage proce-
Laine et al. dures, radiographs and CT are of limited use in
Levigne and Franceschi [97] proposed three early disease detection as they are opaque to
radiographic patterns of RA. These three patterns synovial inflammation.
10.5.3 MRI Findings

a
MR features of shoulder RA involvement include
synovial thickening, joint effusion, joint-space
narrowing, erosions of glenoid, greater tuberosity
and posterolateral humeral head, supraspinatus
and cuff tendon tears, subacromial subdeltoid
bursitis, biceps tenosynovitis, and acromiocla-
vicular joint involvement.
A standard RA scoring system has been devel-
oped, most notably the rheumatoid arthritis MRI
scoring (RAMRIS) system, developed as part of
the Outcome Measures in Rheumatoid Arthritis
Clinical Trials (OMERACT) international initia-
b
tive [98]. Generally, they propose standard field
strength (1.5 T) contrast-enhanced MR imaging
of the wrist and metacarpophalangeal joints to
assign numeric scores for the severity of each of
the three findings: synovitis, marrow edema, and
erosion. Studies have demonstrated good
intra-reader variability but less reliable interreader
performance with this staging method [36].
MR imaging is considered to be the gold stan-
dard for synovial imaging [99]. Currently, two
findings are used as indicators for synovial
inflammation: volume of enhancing synovial tis-
sue and enhancement of the synovium after injec-
tion of contrast. Thickened synovium
demonstrates low-to-intermediate signal inten-
sity on T1-weighted images and high signal
intensity on T2-weighted images (Figs. 10.7 and
10.8). Easily identifiable synovium is usually
thickened synovium. Synovitis and joint effusion Fig. 10.7 47-Year-old patient with RA, same patient as
are the earliest findings in RA on MR images in Fig. 10.1. Axial (a) and coronal oblique (b) fat-
suppressed fluid-sensitive sequence images of the shoul-
(Figs. 10.7 and 10.8). Synovitis is usually appre- der. Typical erosion of the humeral head (black arrows)
ciated as avid or thick enhancement with frond- with adjacent synovitis and pannus. Glenohumeral joint
like morphology, similar to septic arthritis. The effusion and synovitis (white arrow), which extend dis-
signal characteristics of the synovial fluid tend to tally within the biceps tendon sheath (white arrow)
be heterogeneous. In more advanced stages, por-
tions of the synovium may even fail to enhance or [101]. Based on the OMERACT guidelines,
demonstrate relative hypoenhancement and T2 synovitis is defined as enhancement greater than
intermediate-to-low signal intensity, reflecting the width of the joint capsule. New efforts have
fibrous synovitis, although small amounts of made using dynamic contrast-enhanced (DCE)
fibrotic pannus can even be seen earlier in the dis- MR imaging. A gadolinium dose of 0.05–
ease course [100]. Later on, the synovium can 0.3 mmol/kg is used and typically short repetition
turn fatty. time and short echo time T1-weighted gradient-
Active synovitis is best visualized on fat- echo images were acquired every few seconds
suppressed T1-weighted images with contrast over a period of minutes [36]. A curve can be
Fig. 10.8 53-Year-old female patient with RA. Coronal arrow). Fat-suppressed T2-weighted image (b) demon-
oblique proton density-weighted image (a) demonstrates strates glenohumeral joint effusion (black arrow), synovi-
attenuated caliber of the supraspinatus tendon (white tis (black arrow), and extending to the biceps tendon
arrow) and small erosions at the humeral head (black sheath (white arrow)
obtained by plotting signal intensity over time. by the inflamed synovium [99]. Bone marrow
DCE MR imaging of the knees and wrist joints edema seems to be the strongest predictor of
has yielded promising results. Cimmino and col- future erosion [104]. One study showed that if
leagues [102] demonstrated that the enhancement bone edema was present at a specific site at base-
rate of wrist synovium can be used to distinguish line, it was associated with a sixfold increase in
between active and inactive disease. DCE MR the chance of erosion occurrence at the same site
imaging findings have also correlated well with after 1 year [105].
histopathologic findings. Active research is Erosion is defined on MR images as focal loss
focusing on the potential role for DCE MR imag- of normal signal intensity from cortical or sub-
ing in monitoring and helping to appropriately chondral bone on T1-weighted images or focal
time RA treatment with new disease-modifying regions of high signal on T2-weighted sequences
anti-rheumatoid drugs (DMARDs) such as [106]. Erosion enhances on a T1-weighted image
anti-TNFα. Response to more established agents with gadolinium contrast, implying the presence
such as corticosteroids and methotrexate is also of inflamed synovium within the defect. Erosions
under investigation [98, 103]. Since the shoulder can be distinguished from intraosseous cyst or
tends to be involved later in the disease process, cyst-like lesion, because the latter does not
the more recent MRI scoring methods and enhance. Marginal erosions in shoulder RA are
dynamic enhancement protocols have not yet, to usually seen at the posterolateral aspect of the
our knowledge, been applied to the glenohumeral humeral head (Fig. 10.7). In Lehtinen and col-
and acromioclavicular joints. leagues’ [107] series of 148 glenohumeral joints,
Bone marrow edema is an increased signal MR imaging revealed erosive changes in 71
intensity on fat-suppressed fluid-sensitive (48%) of the joints; and erosions were seen on
sequences (Fig. 10.6), representing increased the superolateral articular surface of the humeral
amount of water in the marrow, and may repre- head in 61 of the 71 joints. Glenoid involvement
sent the internal bony response to external attack was only seen in 28 joints. Alasaarela and
colleagues [108] demonstrated the superiority of these two locations are more commonly seen in
MR imaging to ultrasound, CT, and radiograph at patients with septic arthritis. Rarely, a cyst may
identifying humeral head erosions in their pro- grow large enough to be masslike [110].
spective multimodality study. Subacromial subdeltoid bursa fluid can accumu-
Rotator cuff pathology is very common in late from direct inflammation or rotator cuff tear.
patients with RA. This may be related to the Chronic proliferative synovium can over time
destructive effects of the synovitis around the infarct and shed into the bursae or joint, forming
supraspinatus and infraspinatus tendon at their fibrinous joint bodies known as rice bodies with
footprints. MR imaging can depict the tendinosis, varying signal intensity (although generally iso-
partial tear, full-thickness tear, and related fatty tense to muscle).
muscle atrophy (Fig. 10.8). Rotator cuff tears
with muscle atrophy indicated chronicity of the
disease and correlate with functional impairment. 10.5.4 Ultrasound Findings
Both morphologic and functional information are
important to guide treatment, especially in help- Within the past decade, musculoskeletal ultra-
ing identify which patients would benefit from sound (US) has become an established imaging
arthroplasty. With recent more wide use of technique for the diagnosis and follows-up of
reversed shoulder arthroplasty, MR imaging eval- patients with rheumatic disease [111, 112]. Its
uation for rotator cuff and integrity of the deltoid role in diagnostic imaging is continuing to
muscle are increasingly common. expand with the development of further clinical
Acromioclavicular involvement is common in applications and with the advancement of ultra-
RA. On MR imaging, distention of the acromio- sound technology. Owing to the better axial and
clavicular joint capsule with extension of pannus lateral resolution of US, even minute bone sur-
into the joint may be seen at any stage of the dis- face abnormalities may be depicted. Thus
ease. With early distal clavicular osteolysis, there destructive and/or reparative hypertrophic
is subchondral marrow edema disproportionate changes on the bone surface may be seen before
to the acromion. Erosions can enlarge over time they are apparent on plain radiography and com-
to cause osteolysis of the distal clavicle or even parable to magnetic resonance imaging [113].
the acromion. The erosive changes tend to be The “real-time” capability of US allows dynamic
more pronounced at the caudal aspect of the dis- assessment of joint and tendon movements.
tal clavicle. Widening of the joint is common but Advantages of US include its noninvasiveness,
dislocation and subluxation are uncommon [109]. portability, relatively low cost, lack of ionizing
Although it is traditionally taught that acromio- radiation, and its ability to be repeated as often
clavicular joint is involved early and more as necessary, making it particularly useful for the
severely than glenohumeral joint in RA, this has monitoring of treatment [114].
not been our experience. However, when pre- The sonographic features of RA in shoulder
sented with differentiating RA and septic arthritis include joint effusions, active synovitis best seen
which can be quite similar, involvement of the on color Doppler images, biceps tenosynovitis,
acromioclavicular joint, regardless of severity, synovial cysts, subacromial subdeltoid bursitis
makes the diagnosis of RA more likely. and rotator cuff tears, bone erosions, and muscle
Synovial cyst formation and subacromial sub- atrophy. To detect inflammatory lesions the ante-
deltoid bursitis are other common findings in rior, lateral and posterior, and longitudinal and
RA. The synovial cysts develop in the surround- transverse scans with rotation of the shoulder are
ing soft tissue of the shoulder joint and fre- most helpful. A sensitive technique for finding
quently dissect along tendon sheaths. Extension even very small shoulder effusion is the axillary
along the biceps tendon sheath is characteristic. longitudinal scan, but elevation of the arm may
The cysts may also develop under the subscapu- not be possible for patients with advanced
laris or around the axillary recess. However, disease [114].
Biceps tenosynovitis demonstrated as thicken- p osition. The stress position brings the greater
ing of the tendon with anechoic or hypoechoic tuberosity of the humeral head underneath the
fluid accumulation in the tendon sheath. acromion. If there is a considerable reduction in
Alasaarela and Alasaarela found biceps tendinitis its dimensions, then the repeated shearing force
(57%) and changes in the supraspinatus tendon will cause damage to the rotator cuff. They found
(33%) to be the most frequent tendinopathy that in cases of subacromial impingement, the
changes in patients with painful rheumatoid AHD measures less than 6 mm in neutral position
shoulder [115]. Long head of the biceps tendon and shows further reduction (about 25%) in stress
and supraspinatus tendon lesions were also the position.
most common findings of the rheumatic shoulder The involvement of acromioclavicular joint is
in the work of Keysser and Osthus [116]. also a common feature although a small study
Erosions are visualized as steplike or contour found it to be more common in spondyloarthritis
deformities at the humeral head. The humeral compared to RA [119]. Patients with RA have
articular cartilage can be seen between the supra- higher incidence of joint effusions, bursitis, and
spinatus and infraspinatus tendons and the erosions compared to spondyloarthritis.
humeral head. For the visualization of the joint
effusion, distance between joint capsule and infe-
rior margin of infraspinatus tendon above 2 mm 10.6 CPPD and HAD
was considered as a positive sign [117].
Combination of glenohumeral joint effusion, 10.6.1 Definition
bone cartilage reduction, and humeral erosions
was a significant predictor of inflammatory Calcium pyrophosphate dihydrate (CPPD) dis-
nature of the painful shoulder syndrome [117]. ease comprises a spectrum of clinical and imag-
Synovial inflammation in active arthritis leads ing disorders. The nomenclature of CPPD and
to synovial thickening and hyperemia, which can related conditions can seem confusing. The four
be identified on both grayscale and color Doppler terms that are often confused, since some mistak-
images. Synovial thickening usually is enly believe that they are synonymous, are 1.
hypoechoic, noncompressible, or poorly com- CPPD disease, 2. chondrocalcinosis, 3. CPPD
pressible which allows for differentiation from arthropathy, and 4. pseudogout.
fluid. Color Doppler images can demonstrate
vascularity indicating active inflammation. Thus, 1. CPPD disease is an overarching term that
color Doppler images should be included at all refers to the pathologic articular alterations
US exams to help target therapy early in the diag- and destruction that is believed to be the
nosis and to aid in the assessment of treatment response to CPPD crystals within a joint.
responses. 2. Chondrocalcinosis refers to cartilage calcifi-
Real-time imaging capability of US is a par- cation seen on radiography, pathologically or
ticularly advantageous feature, permitting on fluid examination. On radiography calcifi-
dynamic evaluation of a system on movement. cation must be seen in at least two locations to
Nevien El-Liethy et al. proposed that dynamic differentiate systemic disease from dystrophic
US for the diagnosis of shoulder impingement in calcification.
RA should be done in addition to the standard 3. Pyrophosphate or CPPD arthropathy refers
protocol to improve management [118]. The to structural changes of cartilage and bone in
stress position they used is arm semiflexed, semi- the setting of CPPD deposition [120] that
abducted, and hand pronated. The acromiohum- are macroscopically visible or seen radio-
eral distance (AHD) is measured as the minimum graphically. The patterns of joint disease can
distance from the inferior aspect of the acromion closely mimic osteoarthritis or less com-
to the point of entry of the tendon into the acous- monly have more specific patterns. Notably,
tic shadow of the humeral head on neutral cartilage calcification may be absent on
radiographs in patients with pyrophosphate Most of these cases, even when multifocal, are
arthropathy [121]. dystrophic. Richette and colleagues noted that
4. Pseudogout is not a radiologic diagnosis, but a chondrocalcinosis has been reported in 7–10% of
clinical syndrome produced by CPPD crystal individuals around age 60 years [120] and other
deposition disease with intermittent acute studies have found it in up to 60% of individuals
attacks similar to gouty arthritis. Other clinical over the age of 85 years [127, 128]. Hence it
patterns described included pseudo-OA and becomes increasingly difficult in the aging
pseudo-RA, for patients whose clinical presen- patients to use radiographic findings of chondro-
tation mimics osteoarthritis or rheumatoid. calcinosis as differential diagnostic criteria.
In addition to CPPD disease and dystrophic
Ryan and McCarty proposed several diagnos- causes, such metabolic disorders as hemochro-
tic criteria for the diagnosis of CPPD crystal matosis and ochronosis and other heritable
deposition disease [122], including the identifica- genetic mutations should be considered in
tion of CPPD crystal in tissues or synovial fluid patients less than 55 years of age and in patients
by definite means (for example, chemical analy- with significant polyarticular involvement. In
sis) or by compensated polarized light micros- patients more than 55 years of age, hyperparathy-
copy as well as radiographic findings [123, 124]. roidism warrants some consideration when chon-
Hence they described the “disorder” as a combi- drocalcinosis is seen [120].
nation of pathologically visible crystals with cor- The most commonly affected sites are menisci
responding structures/radiographic changes. of the knee, triangular fibrocartilage of the wrist,
At the cellular level, CPPD disease is defined labra of the acetabulum and symphysis pubis,
by the accumulation of CPPD crystals in soft tis- and annulus fibrosus of the intervertebral disk.
sues, most commonly within the extracellular Also noted may be hyaline cartilage, various liga-
matrix of midzonal articular cartilage [125]. It is ments (most commonly the scapholunate and
thought that the initial insult may be a derange- lunatotriquetral), and joint capsule. For some
ment in chondrocyte function that impairs mainte- peculiar reasons the latter two are still termed
nance of the extracellular matrix. This will lead to chondrocalcinosis even though the structures cal-
buildup of excess adenosine triphosphate (ATP), cified are not cartilage.
subsequently, of the inorganic extracellular pyro- Chondrocalcinosis is usually apparent on
phosphate (ePPi) that results from its cleavage radiographs. Hence a chondrocalcinosis survey
[126]. The ePPi in turn binds calcium, producing may be requested. This survey consists of three
crystals. The symptomatic forms of CPPD disease exposures: a frontal view of the pelvis, a frontal
(and other crystal deposition disease) reflect a view encompassing both knees, and one expo-
complex inflammatory cascade that occurs subse- sure with both wrists. Occasionally CPPD
quently. These cascades manifest at synovial and arthropathy can precede radiographically
chondral levels and are mediated by matrix metal- detectable cartilage calcification, although
loproteinases, prostaglandins, toll-like receptors, crystals should be seen on fluid aspiration [124,
and ILs, among other factors [126]. 129]. In one study of 3228 patients, who under-
CPPD disease is classified based on its etiol- went knee arthroscopy, of patients who had
ogy into hereditary, idiopathic, and secondary pathologically proved CPPD crystal deposition,
types associated with metabolic disease and only 39.2% of them had radiographic diagnosis
trauma [122]. of chondrocalcinosis [130].
CT scan is of higher soft-tissue contrast and
cross-sectional capability and thus can detect
10.6.2 Radiographic and CT Findings more subtle chondrocalcinosis as compared to
radiographs. However, due to comparatively high
Chondrocalcinosis is commonly seen in older radiation dose, CT is rarely used for the identifi-
patients. There is no strong gender predilection. cation of chondrocalcinosis alone.
The majority of chondrocalcinosis is caused their classic textbook in 1985. Several of these
by CPPD crystal deposition. However, in 5% of clinical patterns can present at different times
the cases, it can be related to dicalcium phos- during the course of the arthritis. Significant
phate dihydrate and calcium hydroxyapatite number of patients with CPPD crystal deposition
[121]. In terms of shoulder, occasionally, deposi- disease is asymptomatic. The absence of symp-
tion can be seen along the glenoid labra as linear toms occurs in at least 10–20% of documented
density paralleling the glenoid contour or within cases of CPPD crystal deposition disease.
the humeral head articular cartilage. The acro- Recently in 2001, Canhao and colleagues [136]
mioclavicular (AC) joint contains fibrocartilage proposed five clinical presentations based on a
intra-articular disc. CPPD crystal deposition study of 50 patients with confirmed CPPD dis-
preferentially involves fibrocartilage. Thus, ease: pseudogout, pseudo-osteoarthritis, pseudo-
chondrocalcinosis can occur at the AC joint. osteoarthritis with synovitis, monoarthropathy,
Tendon calcifications are frequently seen in and pseudo-rheumatoid.
patients with CPPD crystal deposition disease Pseudogout presentation accounts for about
[124, 131, 132]. An incidence of 13.5% was 25% of CPPD clinical presentations. Usually, the
reported in one study [132]. The most commonly diagnosis is made based on symptoms of acute
involved tendon in the shoulder is supraspinatus. onset of pain, similar to acute gouty flares, in
It appears as linear or punctate calcifications near patients with known CPPD disease. It is believed
the tendon attachment while the calcium that shedding of CPPD crystals into joint fluid
hydroxyapatite crystal deposition tends to be incited an inflammatory response. This can
more homogeneous, discrete, and nodular and develop spontaneously or triggered by direct
also extends distant from the tendon attachment trauma concomitant medical condition such as
[123]. There is a high correlation between pres- myocardial infarction, stroke, joint lavage, gran-
ence of tendon calcifications and extent and ulocyte colony-stimulating factor therapy,
intensity of calcific deposits in other joints [131]. bisphosphonates, and intra-articular hyaluronic
Direct translocation of CPPD crystals from the acid injections [120].
articular or bursal surfaces may be responsible The pseudo-osteoarthritic patterns account
for some of the tendinous calcification [133]. for roughly 50% of pyrophosphate arthropathy.
Additionally calcification of joint capsules can be The imaging findings in these patients greatly
seen as well. Even though it is an oxymoron, cal- resemble degenerative osteoarthritis, however
cifications of capsules, ligaments, and even affecting non-weight-bearing joints such as
sometimes tendons are commonly called radiocarpal, metacarpophalangeal joints, gleno-
“chondrocalcinosis.” humeral joints, and elbow specifically. It is usu-
Pyrophosphate arthropathy is more common ally bilateral and symmetric. The spectrum of
in elderly women. The radiocarpal, first and sec- radiographic findings of osteoarthritis such as
ond metacarpophalangeal joints, and knee are the narrowing of the joint space, subchondral sclero-
most common sites of involvement. In all joints, sis and subchondral cystic changes, and osteo-
the most common appearance is similar to typical phyte formation can be present. However,
osteoarthritis, but more specific changes may be subchondral cysts are one of the hallmarks of
seen such as second and third metacarpal phalan- this condition. They tend to be bigger, numerous,
geal involvement in the hand and lateral and and more widespread when compared to those in
patellofemoral involvement in the knee. Shoulder osteoarthritis. This can go on leading to frag-
involvement is not uncommon. mentation and collapse of the articular surface.
The clinical presentation of CPPD crystal Intra-articular osteochondral bodies thus are
deposition disease is highly variable, and thus it quite common in patients who suffer from CPPD
has been called a “great mimicker” of other arthropathy [137]. Osteophytosis occurs less fre-
arthritides [134]. Ryan and McCarty [135] quently in pyrophosphate arthropathy than in
described six patterns of joint involvement in usual osteoarthrosis [138].
In terms of the glenohumeral joint, primary as linear or punctate hypointense areas. This is
shoulder osteoarthrosis is commonly worse pos- present on spin-echo, fast spin-echo (FSE), and
teriorly with posterior translation of the humeral STIR images [144]. Sometimes, a small halo of
head over the glenoid. In patients with pyrophos- hyperintense signal intensity would be seen sur-
phate arthropathy, when there is associated sec- rounding the hypointense area, which could be
ondary cuff arthropathy, the joint space loss may related to magnetic susceptibility artifacts. The
be worse anteriorly. cartilage calcification is best seen on gradient-
Pseudo-rheumatic arthropathy accounts for echo images (with an echo time greater than
5–8% of pyrophosphate arthropathies. Similar to 5 ms) which produce “blooming” effect to
rheumatoid arthritis, the patient may present with highlight the cartilage calcification. This is from
fatigue, flexion contractures, and bilateral shoul- the local magnetic field inhomogeneity produced
der stiffness, often worse in the mornings [136, by magnetic susceptibility of hyaline cartilage
139]. Laboratory testing often demonstrates ele- and CPPD crystals. Low signal intensity in the
vated ESR. Resnick and colleagues observed that hyaline cartilage of chondrocalcinosis should be
the key radiographic distinction between pseudo- included in the search pattern, especially in older
rheumatic arthropathy and true rheumatoid patients.
arthritis in the setting of coexisting CPPD disease Crystal disease should always be a consider-
is that the former lacks erosions [140]. ation in cases of full-thickness and massive rota-
Occasionally, tumoral deposits of CPPD can tor cuff tears in younger patients (as well as
be seen, especially at the smaller joints (such as secondary impingement in unstable shoulders).
acromioclavicular and temporomandibular CPPD crystal that accumulates in bursal linings
joints). These deposits may actually be within the may trigger or exacerbate a bursitis. In the
small articular discs noted in these locations. In synovium, they may mimic other deposition or
the shoulder, the deposits can cause pressure ero- synovial based processes. The differential diag-
sion or frank destruction of subjacent bone [141]. nosis for this pattern includes hemosiderin, pig-
The deposits tend to be less than 10 cm in size. mented villonodular synovitis (PVNS),
Lobulated margins and location near a joint with- hemophilia, gas related to vacuum phenomenon,
out intra-articular extension are characteristic and various causes of magnetic susceptibility
features. artifacts [138].
Neuropathic type arthropathy can occur in as A combination of significant joint-space nar-
many as 2% of patients [123, 142, 143] with rowing and chondrocalcinosis suggests pyro-
osseous fragmentation, sclerosis, and disorgani- phosphate arthropathy. In pyrophosphate
zation. Thus, pyrophosphate arthropathy should arthropathy, the hallmark of afore-mentioned
be considered in the differential diagnosis of rap- cyst formation can precede joint-space narrowing
idly progressive destruction of large joints. and be easily identified on MR imaging. Thus, on
MR imaging with relatively less dramatic carti-
lage loss but prominent osseous and synovial
10.6.3 MR Findings cysts will raise concern for pyrophosphate
arthropathy.
MR imaging is often used for the evaluation of a
painful joint. Thus, it is quite common to encoun-
ter CPPD crystal deposition disease in older 10.6.4 Ultrasound Findings
patients who are studied with routine MR imag-
ing. Due to its inherent low signal on both T1- High-frequency ultrasound (US) is rapidly grow-
and T2-weighted images, calcification is difficult ing in popularity as a diagnostic means for evalu-
to detect on MR imaging. In this instance, corre- ation of crystal-related arthropathies. By virtue of
lation with radiograph if available would be very both high resolution and degree of sonic
helpful. Usually, the calcification would be seen reflectivity, even minimal deposits of calcium

pyrophosphate crystals can be detected by US tissues are other common sites involved. Although
when the radiograph is otherwise normal [145]. the most recognized manifestation of HAD is cal-
High-frequency US can be used to detect cific tendinitis, calcific periarthritis is the more
articular and juxta-articular alterations and cal- preferred phrase due to the inclusive nature of the
cific deposits in crystal-related disease with phrase.
proven accuracy [145, 146]. The deposition of hydroxyapatite and related
The normal sonographic appearance of artic- calcium phosphate crystals is divided into pri-
ular cartilage is characterized by two sharply mary and secondary processes [149]. For exam-
defined hyperechoic margins delineating an ple, collagen vascular diseases, end-stage renal
anechoic and homogeneous layer. The superfi- disease, and vitamin D intoxication can all result
cial margin is typically thinner than the deeper in secondary deposition of hydroxyapatite. The
one and is optimally visualized when the direc- exact etiology of the primary or idiopathic form
tion of the US beam is perpendicular to the carti- is not yet known. There has been extensive stud-
lage surface. CPPD crystals tend to lie within the ies on the pathophysiology of periarticular HAD,
substance of the hyaline cartilage. The sparkling with most of the research focused on rotator cuff
reflectivity of CPPD crystals allows the clear tendons, one of the most commonly involved
depiction of even minimal aggregates within car- sites.
tilage. The crystal deposition can be focal or dif- One earlier theory favored that calcifications
fuse, leading to “double-contour” sign, which is preferentially deposit in degenerated tendons
created by the permeability of crystal permitting over the health tendon. This proposal was origi-
US waves to penetrate and depict the bone pro- nally championed by Codman [150] that calcifi-
file beneath. Calcification of tendons in CPPD is cation arises within necrotic and dystrophic
typically linear and extensive and may generate tendon fibers that occur naturally with aging.
an acoustic shadow. A study by Filippucci and Recently, the reactive hypothesis proposed by
colleague on patients with established diagnosis Uhthoff and colleagues argues that hydroxyapa-
of gout or CPPD demonstrated high specificity tite deposits in healthy tissue via cell-mediated
of US findings and indicating supraspinatus ten- processes and that the calcifications of HAD pass
don and fibrocartilage of the AC joint are the three distinct stages [151]. The first or pre-calcific
most frequence affected structures in the shoul- stage is marked by fibrocartilaginous metaplasia
der [147]. of tenocytes into chondrocytes. This metaplasia
The ability of US to detect CPPD crystals in may be stimulated by decreased local oxygen
joints with aspirated synovial fluid containing tension, which in turn may be secondary to repet-
CPPD crystals has been investigated with excel- itive compression of tendon fibers. The second,
lent results [148]. Furthermore, US guidance per- calcific stage is further divided into formative,
mits aspiration of even minimal amounts of fluid resting, and resorptive phases. Chalky deposits
within joint, peri-tendinous, or bursal. The develop during the formative phase, and then are
obtained fluid analysis is of utmost importance in bordered by fibrocollagenous tissues during the
establishing the diagnosis of crystal deposition. resting phase when calcium hydroxyapatite accu-
mulation ceases. In the resorptive phase, vascular
channels form around the deposit and provide
10.7 Calcium Hydroxyapatite access to macrophages and multinucleated giant
Deposition Disease (HAD) cells. Then phagocytosis removes the calcium.
Uhthoff and Loehr [151] noted that, during the
10.7.1 Definition resorptive phase, the calcification has a
toothpaste-like, creamy quality and is often under
HAD is characterized by periarticular calcifica- pressure. The third, post-calcific stage is marked
tions, usually in tendons near their osseous attach- by fibroblast proliferation and partial or complete
ments. Bursae, ligaments, and peri-tendinous soft tendon reconstitution.
This disorder is usually monoarticular and setting, radiographic findings play a major role in
most commonly presents between the ages of 40 the diagnosis of HAD [149].
and 70 years and peaks in the fifth decade of life Treatment is often directed at symptom relief,
with a slight male predilection. Gondos made the with most symptoms subsiding in less than
interesting observation that the frequency of 2–3 weeks. NSAIDs are the main treatments
involvement of a joint roughly paralleled its [157]. Local corticosteroid injections and oral or
physiologic range of motion. In his series, calci- parenteral steroids can be used for patients who
fications about the shoulder occurred in 69% of cannot tolerate NSAIDs.
all cases, followed by the hip, elbow, wrist, and Symptomatic deposits can be removed under
knee [152]. This is in contrast to its much less ultrasound with needle puncture, aspiration, and
common involvement of shoulder by CPPD lavage and steroid injection if symptoms do not
deposition disease. However, clinical findings in resolve quickly. Extracorporeal shockwave ther-
both HAD and CPPD can be quite similar. apy has been advocated by some; a recent meta-
Bosworth reviewed more than 6000 shoulders analysis by Lee and colleagues [158] concluded
and found HAD deposits in 2.7%; but of these level B support for this technique in recalcitrant
only 30% were symptomatic. Half of the affected cases [159]. Surgical debridement remains the
cases showed bilateral calcifications [153]. definitive treatment for refractory calcific tendini-
When symptomatic, patients present with pain, tis, with postoperative physical therapy identified
erythema, swelling, and limitation of motion of as a critical component expediting return to base-
the neighboring joint [154]. The most symptom- line activity levels. Concomitant subacromial
atic of the HAD stages is the calcific stage, spe- decompression has fallen out of favor because of
cifically during its resorptive phase. These effects longer recovery times and no demonstrable added
are thought to result from rupture of a calcific benefit on 5-year outcome analysis [160].
deposit into an adjacent soft-tissue space or bursa,
causing an acute self-limited inflammatory reac-
tion. Phagocytosis of hydroxyapatite crystals by 10.7.2 Radiographic and CT Findings
neutrophils and macrophages results in the release
of lysosomal enzymes and other inflammatory Initially, HAD presents as a thin, cloudlike,
mediators [155, 156]. This condition is known as poorly defined clump of calcification in periar-
acute calcific periarthritis. The pain often mimics ticular soft tissues such as tendons, ligaments,
subacromial impingement, being elicited or exac- bursae, or synovium. Later the calcifications
erbated by recurrent or prolonged abduction. become denser and more homogenous with well-
Clinically, HAD can be accompanied by fever and defined margins. Deposits can remain static over
can mimic an infection, especially in the resorp- the years. They also can enlarge, change shape,
tive stage. Normal erythrocyte sedimentation rate or disappear. Rarely, the crystals can deposit in
and leukocyte count are distinguishing character- the joint [161]. Recognition of the dynamic
istics that differentiate HAD from infection [154]. nature of the process is very important in avoid-
More chronic and dull pain is seen in patients during some diagnostic pitfalls. The region of
ing other stages of HAD. hydroxyapatite deposition may show variable
The definitive diagnosis of HAD is made by consistency and may spontaneously decrease or
identifying hydroxyapatite and related calcium increase in size and may cause local intense
phosphate crystals (such as octacalcium phos- inflammatory reaction in the soft tissues and
phate, carbonate apatite, and calcium triphos- occasionally erosion in adjacent bone (Fig. 10.9).
phate) in the affected joint. Since this requires Several authors have proposed various classi-
electron microscopy, electron diffraction studies, fication systems based on the size of the deposits
or a specialized alizarin red S stain which are all on the radiograph, stage of the disease process,
impractical diagnostic tools in the routine clinical and its morphological appearances.
a b
c d
Fig. 10.9 Calcific tendinitis with possible secondary demonstrates interval change to linear calcification along
osseous involvement. Frontal view radiograph of the the humeral head (black arrow) and underlying cystic
right shoulder (a), sagittal reformatted CT images of the erosions (black arrow) with some vague calcification
right shoulder (b, c), and coronal oblique fat-suppressed within (white arrow), indicating migration of the calcifi-
fluid-sensitive MR image (d) of the same patient. The CT cation into the osseous structure. Coronal oblique MR
and MRI images were obtained about 4 months later after image (d) demonstrates the erosion at the humeral head
the radiograph. Frontal radiograph A demonstrates glob- (black arrow). Incidentally noted is a chondroid lesion in
ular HAD (black arrow) around the humeral head. CT of the proximal humerus
the right shoulder (b, c) approximately 4 months later
Bosworth proposed the classification based on De Palma and Kruper had classified these
the size of the deposits [162]. Large deposits are appearances into two main types: Type 1 has a
the ones measuring 1.5 cm or more in their great- fluffy, fleecy appearance that corresponds to the
est profile dimension, medium-size deposits are resorptive phase. Occasionally, there is crescentic
the ones measuring less than 1.5 cm, and tiny shaped streaky density above the fluffy deposits;
deposits are the ones that can be seen only on this suggests extrusion into the overlying bursa
fluoroscopy. (Fig. 10.10). Type 2 deposits correspond to the
a b
Fig. 10.10 Calcific tendinitis/bursitis. Frontal view of appears as teardrop or crescent-shaped radiodense area
the right shoulder (a) and coronal oblique fat-suppressed (white arrows) below acromion and deltoid (a) and con-
fluid-sensitive weighted (b) images of the same patient. firmed on MRI image (b)
Subacromial subdeltoid bursa calcification usually
late formative stage, and are marked by homoge- rotation views of the shoulder and move medially
neous, more defined calcific densities. It is usu- on the internal rotation view. Calcifications of the
ally ovoid in shape, and occasionally triangular infraspinatus and teres minor tendons are best
and linear shape can be seen [163]. seen in profile on internal rotation anteroposte-
Mole developed the classification system rior views, lateral to the humeral head. The for-
based on the morphology [164]: mer moves laterally on external rotation views.
Subscapularis tendon calcifications are better
• Type A: Calcification dense, homogenous seen on the axillary view, close to the lesser
with clear contours tuberosity of the humeral head. In contrast, sub-
• Type B: Calcification dense split/separated acromial subdeltoid bursa calcification appears
with clear contours as oval or teardrop-shaped radio-dense area
• Type C: Calcification nonhomogeneous ser- superior to the humeral head but below the acro-
rated contours mion (Fig. 10.10).
• Type D: Calcification as dystrophic calcifica- In the study by Loew and colleagues, they
tion of the insertion in continuity with the found that the site with the highest incidence of
tuberosity HAD deposits was broadened to include not only
the supraspinatus tendon but also the adjoining,
The shoulder is the most common site of cranial portion of the subscapularis [167]. The
HAD, accounting for 60% of cases of acute cal- study further reported that most supraspinatus
cific periarthritis [165]. Periarticular calcifica- deposits lie in the midportion of the tendon or
tions in one or both shoulders occur in as many as just subjacent to its acromial surface. Uhthoff and
7.5% of adults [165]. Loehr [151] observed that it is uncommon for
Calcifications can be seen in any of the rotator intratendinous HAD deposits to contract the bone
cuff tendons, with the supraspinatus tendon being surface because they are generally 1.5 or 2 cm
the most common site. In order of decreasing fre- away from it. In the case of the supraspinatus,
quency, the infraspinatus, teres minor, and sub- this corresponds to the critical zone thought to be
scapularis may be affected [166]. These calcific the region most susceptible to tears because of its
deposits around supraspinatus tend to be around relatively diminished vascularity and/or lower
the greater tuberosity on anteroposterior external oxygen tension. However, rotator cuff tears are
not common in the setting of calcific periarthritis. erosion at the tendinous insertion may occur, and
In their study population, only one patient had a the juxtaposition of the erosive change and the
coexistent partial-thickness tear, and only one insertional HAD deposit can radiographically
patient had intraosseous extension of the calcifi- mimic a destructive juxtacortical, partially min-
cation. Multiple other studies have corroborated eralized mass. The few reported cases in the lit-
this lack of correlation between HAD and rotator erature have noted that the HAD deposit
cuff tears. When tears do occur, they tend to spontaneously resolved over 6–10 weeks [169–
occur more often in the setting of small rather 171]. In worrisome cases, biopsy may be per-
than large deposits [168]. The characteristic loca- formed, and psammomatous bodies can confirm
tion of calcifications within the critical zone can HAD and exclude neoplasm.
be used to distinguish HAD from degenerative
calcifications.
HAD can also be seen in the origin of the long 10.7.3 MR Findings
head of the biceps above the glenoid fossa, and
below the coracoid at the origin of the short head The calcification of HAD is hard to identify on
of the biceps and coracobrachialis tendons. MR due to its inherent low signal (Fig. 10.11).
Calcifications adjacent to the inferior margin of Zubler and colleagues concluded from a study of
the glenoid indicate HAD at the origin of the tri- 62 MR shoulder arthrograms that MR imaging
ceps tendon. alone is unreliable for diagnosis of HAD [172].
The pectoralis major tendon calcifications are However, sometimes there is edema in the adja-
seen along the anterior margin of the proximal cent marrow and soft tissue (Fig. 10.11), which
humeral shaft, specifically along the lateral lip of increases its conspicuity, and raises the concern
the distal aspect of the bicipital groove. Erosions for differential diagnosis of infection, injury, or
within the humerus are rare when HAD involves neoplasm [173]. Image interpreters need to be
rotator cuff, although sometimes they can be seen vigilant for detection of ovoid-shaped low signal
in cases of pectoralis calcific tendinitis. Cortical foci around the rotator cuff tendon in our search
a b
Fig. 10.11 Calcific tendinitis. Sagittal oblique proton thin rim of signal hyperintensity (black arrow) around the
density (a) and sagittal oblique fat-suppressed, fluid- HAD deposit (white arrow) compatible with peri-tendon
sensitive weighted (b) MR images. a demonstrates focal edema and highlights the focal calcification which was
low signal circumscribed HAD deposits (white arrow) less obvious on the proton density images of (a)
along the subscapularis tendon anteriorly. b demonstrates
pattern. In the resorptive and inflammatory stages bursal or tendon calcification can be distin-
adjacent high T2 signal and bursitis are frequent. guished. In this assessment, the sensitivity of
Loew and colleagues [167] set out attempting ultrasound diagnosis was reported at 94% with
to determine whether MR imaging appearances specificity at 99% and accuracy at 99% [177].
of calcific tendinitis in 76 patients correlated with Calcification along the rotator cuff can be seen
the feature of osseous subacromial impingement. as hyperechoic focus with acoustic shadow, no
They concluded that there was no significant cor- shadow, or faint shadow [177]. The more discrete
relation, but did observe three distinct MR imag- and well-defined calcification of the resting phase
ing morphologies of rotator cuff HAD in 71 of on radiograph tends to create more acoustic shad-
their patients. Type A (54%) appearance is a owing on ultrasound. During the resorptive
compact, homogenous, single deposit with a phase, the calcification on radiograph is ill
defined outline. Type B (38%) appearances were defined and usually shows no or very little acous-
subdivided rather than solitary but remained tic shadowing on ultrasound.
homogenous and well defined. Type C (7%) Ultrasound has been shown to detect most of
appearance is diffuse low signal intensity without the big and small scattered calcifications around
a defined outline. In 45 patients in their study, a the rotator cuff. However, the shadow of acro-
band of T2 signal hyperintensity surrounded the mion makes the subacromial calcification hard to
calcification and was thought to represent perifo- detect on ultrasound. However, this kind of calci-
cal edema. fication around the myotendinous junction is
Osseous involvement as cortical erosion and rare. Calcifications can interference diagnosis of
bone marrow edema is gaining more recognition rotator cuff tear on ultrasound because the calci-
recently. Hayes and colleagues [174] first fication can obscure the structure behind.
described this phenomenon in 1987, presenting a Larger calcifications located at the location of
case series of five patients with calcific tendinosis the confluence of the supraspinatus and infraspi-
in pectoralis major, gluteus maximus, and adduc- natus tendon are found to be most symptomatic
tor magnus tendons with associated cortical ero- [178]. The symptomatic calcific tendinitis may
sion at the tendon insertion sites. This author cause adjacent focal thickening of the tendon on
hypothesized that bone resorption may be sec- ultrasound images. The advantage of ultrasound
ondary to increased vascularity and inflammation diagnosis is that when probed percutaneously,
at the tendon site or alternatively may be due to there may be elicited pain. A concomitant sub-
adjacent mass effect. Recently, Flemming and acromial subdeltoid bursa formation can be eas-
colleagues [175] retrospectively reviewed 50 ily identified on the ultrasound. Some authors
cases of osseous involvement in calcific tendino- have showed that the presence of a power
sis and found 11 patients with cortical erosions in Doppler signal near the tendon calcification is
the shoulder. Even less commonly described is more common in patients with symptomatic cal-
the associated bone marrow edema, which may cifications than in individuals with asymptom-
occur with or without cortical erosion (Fig. 10.9) atic calcifications [179].
[176]. This may lead to difficulties in differentiat-
ing this entity from other diagnostic consider-
ations such as neoplasm and infection [176]. 10.8 Milwaukee Shoulder
10.8.1 Definition
10.7.4 Ultrasound Findings
Milwaukee shoulder is a destructive arthropathy
Ultrasound can accurately depict the location, that results from the less common intra-articular
morphology, and size of the calcific deposits on accumulation of hydroxyapatite crystals. Symptoms
the rotator cuff. Additionally, with sonography, are usually comparatively mild, despite rapid and
the calcification can be localized by depth so that marked progression seen radiographically.
The term Milwaukee shoulder syndrome was have shown to be effective. Colchicine has been
first used in 1981 by McCarty and colleagues shown to be effective in the management [185].
[180] to describe four elderly women from Physiotherapy also has a major role, which pro-
Milwaukee, Wisconsin, who presented with vides the required exercise to help the patient to
recurrent bilateral shoulder joint effusions, radio- maintain the range of motion and strengthen
graphic findings of severe destructive changes of the surrounding muscles. For large effusions,
the glenohumeral joints, and massive tears of the arthrocentesis is beneficial. Surgical interven-
rotator cuff. tion, such as partial or total arthroplasty, is con-
The knees are affected in 50% of the cases sidered in severe or advanced cases, provided
with pyrophosphate-like arthropathy [181]. There that there are no contraindications. More recent
is some contention about whether the entity studies have suggested some benefits from tidal
purely involves HAD crystals or also involves irrigation [186].
coexistent intra-articular CPPD deposition [138].
The classic features described by McCarty [182,
183] include pain, loss of joint function, and effu- 10.8.2 Radiographic and CT Findings
sion. In their original series of 30 patients and
through their analysis of 42 additional patients Imaging features of Milwaukee shoulder overlap
who had been reported in other studies, they with those of other arthropathies and not infre-
noted that Milwaukee shoulder favored female quently resemble neuropathic joint. The main
patients by a 4:1 ratio. The mean age is 72 years imaging differential diagnoses include rapidly
of age. Bilaterality of involvement was observed destructive or progressing arthropathy, septic
in 82% of the cases. The dominant arm was arthritis, neuropathic arthropathy, osteonecrosis,
always involved and the nondominant arm, when inflammatory arthropathy, crystal-associated
involved, often demonstrated less dramatic arthropathy, and arthropathy of late syphilis.
changes. However, this pattern is common in Joint-space narrowing and destruction of sub-
most arthropathies. In their series, the patient’s chondral bone are the hallmarks of the Milwaukee
pain tended to be mild or intermittent, but shoulder. Joint effusion is a cardinal feature and
restricted range of motion was more universal. these tend to be large. Superior migration of the
Potential predisposing factors were previous humeral head can be seen as a secondary sign of
trauma (nine patients), CPPD disease (eight underlying, related, rotator cuff tear. There are
patients), neuroarthropathy (three patients), associated scalloping of the undersurface of the
dialysis-associated arthropathy (one patient), and acromion, forming pseudoarticulation. This fea-
idiopathic (ten patients). ture can be seen in all causes of rotator cuff
The precise cause of Milwaukee shoulder is arthropathy, and is termed acetabularization of
unknown. However, intra-articular HA crystals the acromion; the changes in the humeral head
are thought to incite a chronic synovitis that are called femurization.
eventually triggers the release of proteases and Soft-tissue swelling, capsular calcification,
collagenases. These substances degrade both and intra-articular bodies can be seen. Severe and
cartilage and bone. Secondary destabilization of focal osteoporosis of the humeral head is typical.
the joint resulting from these processes may Glenohumeral osteophytes tend to be small or
promote subclinical destruction [184]. absent. Subchondral cystic changes are not as
Periarticular calcifications frequently accumu- prominent as in pure pyrophosphate arthropathy.
late as well over the course of the disease, and in
time the periarticular tissues can also undergo
significant destruction. 10.8.3 Ultrasound Findings
The treatment of Milwaukee shoulder is usu-
ally supportive; resting the affected joint and Ultrasonography of the shoulder usually shows
use of nonsteroidal anti-inflammatory agents fluid collection and synovial proliferation.
10.8.4 MRI Findings 13. Bashir A, Gray ML, Boutin RD, Burstein
D. Glycosaminoglycan in articular cartilage: in vivo
assessment with delayed Gd (DTPA) (2-)-enhanced
Full-thickness rotator cuff tear is common. MR imaging. Radiology. 1997;205:551–8.
McCarty even noted that original descriptions of 14. Bashir A, Gray ML, Harke J, Burstein D. Non-
HAD dating to the mid-nineteenth century identi- destructive imaging of human cartilage
glycosaminoglycan concentration by MRI. Magn

fied loss of the intra-articular segment of the long Reson Med. 1999;41:857–65.
head of the biceps tendon as another typical 15. Reddy R, Insko EK, Noyszewski EA, et al. Sodium
feature [182]. MRI of human articular cartilage in vivo. Magn
Large joint effusion, thinning of the glenoid Reson Med. 1998;39:697–701.
16. Regatte RR, Akella SV, Borthakur A, Kneeland JB,
cartilage, and subchondral destructions are other Reddy R. In vivo proton MR three-dimensional T1ρ
finds that can be well documented on MRI. mapping of human articular cartilage: initial experi-
ence. Radiology. 2003;229(1):269–74.
17. Brossmann J, Frank LR, Pauly JM, et al. Short
echo time projection reconstruction MR imaging of
References cartilage: comparison with fat-suppressed spoiled
GRASS and magnetization transfer contrast MR
1. Lawrence RC, Felson DT, Helmick CG, et al. imaging. Radiology. 1997;203:501–7.
Estimates of the prevalence of arthritis and 18. Bianchi S, Martinoli C. Detection of loose bodies in
other rheumatic conditions in the United States. joint. Radiol Clin N Am. 1999;37:679–90.
II. Arthritis Rheum. 2008;58(1):26–35. 19. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear
2. Altman R, Asch E, Block D, Bole G, Borenestein arthropathy. J Bone Joint Surg Am. 1983;65(9):
D, Brankt K, et al. Development of criteria for 1232–44.
the classification and reporting of osteoarthri- 20. Collins DN, Harryman DT 2nd. Arthroplasty for
tis. Classification of osteoarthritis of the knee. arthritis and rotator cuff deficiency. Orthop Clin
Diagnostic and therapeutic criteria committee of North Am. 1997;28(2):225–39.
the American Rheumatism Association. Arthritis 21. Macaulay AA, Greiwe RM, Bigliani LU. Rotator
Rheum. 1986;29(8):1039–49. cuff deficient arthritis of the glenohumeral joint.
3. Philips WC Jr, Kattapuram SV. Osteoarthritis: with Clin Orthop Surg. 2010;2(4):196–202.
emphasis on primary osteoarthritis of the shoulder. 22. Ecklund JK, Lee TQ, Tibone J, Gupta R. Rotator
Del Med J. 1991;63(10):609–13. cuff tear arthropathy. J Am Acad Orthop Surg.
4. Kerr R, Resnick D, Pineda C, Haghighi 2007;15(6):340–9.
P. Osteoarthritis of the glenohumeral joint: a 23. Feeley BT, Gallo RA, Craig EV. Cuff tear arthropa-
radiologic-pathologic study. AJR. 1985;144:967–72. thy: current trends in diagnosis and surgical manage-
5. dePalma AF. Surgery of the shoulder. 3rd ed. ment. J Shoulder Elb Surg. 2009;18(3):484–94.
Philadelphia: Lippincott; 1983. p. 211–41. 24. Jensen KL, Williams GR Jr, Russell IJ, Rockwood
6. Kernwein GA. Roentgenographic diagnosis of CA Jr. Rotator cuff tear arthropathy. J Bone Joint
shoulder dysfunction. JAMA. 1965;194:179–83. Surg Am. 1999;81(9):1312–24.
7. Neer CS. Replacement arthroplasty for glenohumeral 25. Zeman CA, Arcand MA, Cantrell JS, Skedros JG,
osteoarthritis. J Bone Joint Surg Am. 1974;56:1–13. Burkhead WZ Jr. The rotator cuff-deficient arthritic
8. Green A, Norris TR. Imaging techniques for gle- shoulder: diagnosis and surgical management. J Am
nohumeral arthritis and glenohumeral arthroplasty. Acad Orthop Surg. 1998;6(6):337–48.
Clin Orthop Rel Res. 1994;307:7–17. 26. Visotsky JL, Basamania C, Seebauer L, Rockwood
9. Walch G, Boulahia A, Boileau P, Kempf JF. Primary CA, Jensen KL. Cuff tear arthropathy: pathogenesis,
glenohumeral osteoarthritis: clinical and radio- classification, and algorithm for treatment. J Bone
graphic classification. The Aequalis Group. Acta Joint Surg Am. 2004;86(Suppl 2):35–40.
Orthop Belg. 1998;64(Suppl 2):46–52. 27. Nam D, Maak TG, Raphael BS, Kepler CK, Cross
10. Graichen J, Jakob J, von Eisenhart-Rothe R, et al. MB, Warren RF. Rotator cuff tear arthropathy:
Validation of cartilage volume and thickness mea- evaluation, diagnosis, and treatment: AAOS exhibit
surements in the human shoulder with quantitative selection. J Bone Joint Surg Am. 2012;94(6):e24.
magnetic resonance imaging. Osteoarthr Cartil. 28. Hamada K, Fukuda H, Mikasa M, Kobayashi
2003;11:475–82. Y. Roentgenographic findings in massive rotator cuff
11. Vasnawala SS, Pauly JM, Nishimura DG, tears: a long-term observation. Clin Orthop Relat
Gold GE. MR imaging of knee cartilage with Res. 1990;254:92–6.
FEMR. Skelet Radiol. 2002;31:574–80. 29. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G,
12. Hargreaves BA, Gold GE, Beaulieu CF, et al. Molé D. Grammont inverted total shoulder arthro-
Comparison of new sequences for high-resolution plasty in the treatment of glenohumeral osteoar-
cartilage imaging. Magn Reson Med. 2003;49:700–9. thritis with massive rupture of the cuff. Results
of a multicentre study of 80 shoulders. JBJS. 47. Greenspan A, Tehranzadeh J. Imaging of infectious

2004;86(3):388–95. arthritis. Radiol Clin N Am. 2001;39(2):267–76.
30. Saupe N, Pfirrmann CW, Schmid MR, Jost B, 48. Rutten MJ, van den Berg JC, van den Hoogen
Werner CM, Zanetti M. Association between rota- FH, et al. Nontuberculous mycobacterial bursi-
tor cuff abnormalities and reduced acromiohumeral tis and arthritis of the shoulder. Skelet Radiol.
distance. AJR. 2006;187(2):376–82. 1998;27(1):33–5.
31. Klinger HM, Baums MH, Freche S, et al. Septic 49. Kapukaya A, Subasi M, Burke Y, et al. Tuberculosis
arthritis of the shoulder joint: an analysis of of the shoulder joint. Joint Bone Spine.
management and outcome. Acta Orthop Belg. 2006;73(2):177–81.
2010;76(5):598–603. 50. Recht MP, Kramer J, Petersilge CA, et al. Distribution
32. Mehta P, Schnall SB, Zalavras CG. Septic arthritis of normal and abnormal fluid collections in the gle-
of the shoulder, elbow, and wrist. Clin Orthop Relat nohumeral joint: implications for MR arthrography.
Res. 2006;451:42–5. J Magn Reson Imaging. 1994;4(2):173–7.
33. Cleeman E, Auerbach JD, Klingenstein GG, et al. 51. Schweitzer ME, Magbalon MJ, Fenlin JM, et al.
Septic arthritis of the glenohumeral joint: a review Effusion criteria and clinical importance of glenohu-
of 23 cases. J Surg Orthop Adv. 2005;14(2):102–7. meral joint fluid: MR imaging evaluation. Radiology.
34. Leslie BM, Harris JM III, Driscoll D. Septic arthri- 1995;194(3):821–4.
tis of the shoulder in adults. J Bone Joint Surg Am. 52. Bremell T, abdelnour A, Tarkowski A.
1989;71(10):1516–22. Histopathological and serological progression of
35. Peiffenberger J, Meiss L. Septic conditions of the experimental Staphylococcus aureus arthritis. Infect
shoulder- an up-dating of treatment strategies. Arch Immun. 1992;60(7):2976–85.
Orthop Trauma Surg. 1996;115(6):325–31. 53. Karchevsky M, Schweitzer ME, Morrison WB,
36. Sussmann AR, Cohen J, Nomikos GC, Schweitzer et al. MRI findings of septic arthritis and associ-
ME. Magnetic resonance imaging of shoulder ated osteomyelitis in adults. AJR Am J Roentgenol.
arthropathies. Magn Reson Imaging Clin N Am. 2004;182(1):119–22.
2012;29(2):349–71. 54. Graif M, Schweitzer ME, Deely D, Matteucci T. The
37. Resnick D, Niwayama G. Osteomyelitis, septic septic versus nonseptic inflamed joint: MRI charac-
arthritis, and soft tissue infection. In: Resnick D, teristics. Skelet Radiol. 1999;28(11):616–20.
Niwayama G, editors. Diagnosis of bone and joint 55. Bierry G, Huang AJ, Chang CY, Torriani M, Bredella
disorders, vol. 3. 4th ed. Philadelphia: WB Saunders; MA. MRI findings of treated bacterial septic arthri-
2002. p. 2419–35. tis. Skelet Radiol. 2012;41(12):1509–16.
38. Cofield RH. The shoulder: results of complications. 56. Lutz AM, Seemayer C, Corot C, et al. Detection
In: Morey BF, Cooney WPI, editors. Joint replace- of synovial macrophages in an experimental rabbit
ment arthroplasty. New York: Churchill Livingstone; model of antigen-induced arthritis: ultrasmall super-
1991. p. 437–53. paramagnetic iron oxide-enhanced MR imaging.
39. Silliman JF, Hawkins RJ. Complications follow- Radiology. 2004;233(1):149–57.
ing shoulder arthroplasty. In: Friedman RJ, editor. 57. Bierry G, Jehl F, Neuville A, et al. MRI of mac-
Arthroplasty of the shoulder. New York: Thieme; rophages in infectious knee synovitis. AJR Am J
1994. p. 242–53. Roentgenol. 2010;194(6):W521–6.
40. Mohana-Borges AV, Chung CB, Resnick 58. Lutz AM, Weishaupt D, Persohn E, et al. Imaging
D. Monoarticular arthritis. Radiol Clin N Am. of macrophages in soft-tissue infection in rats: rela-
2004;42(1):135–49. tionship between ultrasmall superparamagnetic iron
41. Shirtliff ME, Mader JT. Acute septic arthritis. Clin oxide dose and MR signal characteristics. Radiology.
Microbiol Rev. 2002;15(4):527–44. 2005;234(3):765–75.
42. Dubost JJ, Soubrier M, De Champs C, et al. No 59. Heale JP, Speert DP. Macrophages in bacterial infec-
changes in the distribution of organisms responsible tion. In: Burke B, Lewis CE, editors. The macro-
for septic arthritis over a 20 year period. Ann Rheum phage. 2nd ed. Oxford: Oxford University Press;
Dis. 2002;61(3):267–9. 2002. p. 210–52.
43. Ho G Jr. Bacterial arthritis. Curr Opin Rheumatol. 60. Sigovan M, Boussel L, Sulaiman A, et al. Rapid-
2001;13(4):310–4. clearance iron nanoparticles for inflammation imag-
44. Stimmler MM. Infectious arthritis: tailoring ini- ing of atherosclerotic plaque: initial experience in
tial treatment to clinical findings. Postgrad Med. animal model. Radiology. 2009;252(2):401–9.
1996;99(4):127–31.. (discussion 135-9) 61. Hyafil F, Laissy JP, Mazighi M, et al. Ferumoxtran-
45. Swan A, Amer H, Dieppe P. The value of syno- 10- enhanced MRI of the hypercholesterolemic
vial fluid assays in the diagnosis of joint disease: rabbit aorta: relationship between signal loss and
a literature survey. Ann Rheum Dis. 2002;61: macrophage infiltration. Arterioscler Thromb Vasc
493–8. Biol. 2006;26(1):176–81.
46. Yoshikawa TT. Antimicrobial resistance and aging: 62. Lefevre S, Ruimy D, Neuville A, et al. Septic arthri-
beginning of the end of the antibiotic era? J Am tis: monitoring with USPIO-enhanced macrophage
Geriatr Soc. 2002;50(7 suppl):S226–9. MR imaging. Radiology. 2011;258(3):722–8.
63. Richter R, Hahn H, Nubling W, et al. Shoulder gir- 80. van den Berg WB. Lessons from animal mod-
dle and shoulder joint tuberculosis. Z Rheumatol. els of osteoarthritis. Curr Opin Rheumatol.
1985;44(2):87–92.. (in German) 2001;13(5):452–6.
64. Griffith JF, Peh WC, Evans NS, et al. Multiple 81. Tak PP, Bresnihan B. The pathogenesis and pre-
rice body formation in chronic subacromial/sub- vention of joint damage in rheumatoid arthritis:
deltoid bursitis: MR appearances. Clin Radiol. advances from synovial biopsy and tissue analysis.
1996;51(7):511–4. Arthritis Rheum. 2000;43(12):2619–33.
65. Hayter CL, Koff MF, Shah P, et al. MRI after arthro- 82. Philippe L, Alsaleh G, Suffert G, Meyer A, Georgel
plasty: comparison of MAVRIC and conventional P, Sibilia J, Wachsmann D, Pfeffer S. TLR2 expres-
fast spin-echo techniques. AJR Am J Roentgenol. sion is regulated by microRNA miR-10 in rheu-
2011;197(3):W405–11. matoid fibroblast-like synoviocytes. J Immunol.
66. Chen CA, Chen W, Goodman SB, et al. New MR 2012;188(1):454–61.
imaging methods for metallic implants in the knee: 83. Hämälainen N. Epidemiology of upper limb joint
artifact correction and clinical impact. J Magn Reson affections in rheumatoid arthritis. In: Baumgartner
Imaging. 2011;33(5):1121–7. H, Dvorak J, Grob D, Munzinger U, Simmen B,
67. Koch KM, Brau AC, Chen W, et al. Imaging near editors. Rheumatoid arthritis: current trends in diag-
metal with a MAVRIC-SEMAC hybrid. Magn nostics, conservative treatment, and surgical recon-
Reson Med. 2011;65(1):71–82. struction. Stuttgart: Georg Thieme Verlag; 1995.
68. Widman DS, Craig JG, van Holsbeeck p. 158–61.
MT. Sonographic detection, evaluation and aspira- 84. Lehtinen JT, Lehto MU, Kaarela K, Kautiainen HJ,
tion of infected acromioclavicular joints. Skelet Belt EA, Kauppi MJ. Radiographic joint space in
Radiol. 2001;30:388–92. rheumatoid glenohumeral joints. A 15-year prospec-
69. Garcia-De La Torre I. Advances in the manage- tive follow-up study in 74 patients. Rheumatology
ment of septic arthritis. Infect Dis Clin N Am. (Oxford). 2000;39:288–92.
2006;20(4):773–88. 85. Cruess RL. Corticosteroid-induced osteonecro-
70. Gordon JE, Huang M, Dobbs M, et al. Causes of sis of the humeral head. Orthop Clin North Am.
false-negative ultrasound scans in the diagnosis 1985;16(4):789–96.
of septic arthritis of the hip in children. J Pediatr 86. Ennevaara K. Painful shoulder joint in rheuma-
Orthop. 2002;22:312–6. toid arthritis. A clinical and radiological study of
71. Zubler V, Mamisch-Saupe N, Pfirrmann CW, et al. 200 cases, with special reference to arthrography
Detection and quantification of glenohumeral joint of the glenohumeral joint. Acta Rheumatol Scand.
effusion: reliability of ultrasound. Eur Radiol. 1967;Suppl 11:11–116.
2011;21(9):1858–64. 87. Smith AM, Sperling JW, Cofield RH. Arthroscopic
72. Michel BA, Bloch DA, Wolfe F, Fries JF. Fractures rotator cuff debridement in patients with rheumatoid
in rheumatoid arthritis: an evaluation of associated arthritis. J Shoulder Elb Surg. 2007;16(1):31–6.
risk factors. J Rheumatol. 1993;20:1666–9. 88. Chen AL, Joseph TN, Zuckerman JD. Rheumatoid
73. Kirwan JR, Silman AJ. Epidemiological, sociologi- arthritis of the shoulder. J Am Acad Orthop Surg.
cal and environmental aspects of rheumatoid arthri- 2003;11:12–24.
tis and osteoarthrosis. Baillieres Clin Rheumatol. 89. van der Zwaal P, Pijls BG, Thomassen BJ,
1987;1(3):467–89. Lindenburg R, Nelissen RG, van de Sande MA. The
74. Kirwan JR. Rheumatology out-patient work- natural history of the rheumatoid shoulder: a pro-
load increases inexorably. Br J Rheumatol. spective long-term follow-up study. Bone Joint J.
1997;36(4):481–6. 2014;96-B(11):1520–4.
75. Arnett FC. Goldman: Cecil text-book of medicine. 90. Petersson CJ. The acromioclavicular joint in
In: Rheumatoid arthritis. 21st ed. Philadelphia: rheumatoid arthritis. Clin Orthop Relat Res.
W. B. Saunders Co; 2000. 1987;223:86–93.
76. McInnes IB, Schett G. The pathogenesis of rheu- 91. van der Heijde DM. Plain X-rays in rheumatoid
matoid arthritis. N Engl J Med. 2011;365(23): arthritis: overview of scoring methods, their reli-
2205–19. ability and applicability. Baillieres Clin Rheumatol.
77. Felson DT, Klareskog L. The genetics of rheuma- 1996;10(3):435–53.
toid arthritis: new insights and implications. JAMA. 92. Arnett FC, Edworthy SM, Bloch DA, McShane DJ,
2015;313(16):1623–4. Fries JF, Cooper NS, et al. The American rheuma-
78. Cooles FA, Isaacs JD. Pathophysiology of rheumatism association 1987 revised criteria for the clas-
toid arthritis. Curr Opin Rheumatol. 2011;23(3): sification of rheumatoid arthritis. Arthritis Rheum.
233–40. 1988;31(3):315–24.
79. Hitchon CA, Chandad F, Ferucci ED, et al. 93. Tugwell P, Boers M. OMERACT conference on out-
Antibodies to porphyromonas gingivalis are asso- come measures in rheumatoid arthritis clinical trials:
ciated with anticitrullinated protein antibodies in introduction. J Rheumatol. 1993;20(3):528–30.
patients with rheumatoid arthritis and their relatives. 94. Larsen A, Dale K, Eek M. Radiographic evalua-
J Rheumatol. 2010;37(6):1105–12. tion of rheumatoid arthritis and related conditions
by standard reference films. Acta Radiol Diagn. 109. Lehtinen JT, Lehto MU, Kaarela K, et al.
1977;18:481–91. Acromioclavicular joint subluxation is rare in rheu-
95. Laine VAI, Vainio KJ, Pekanmäki K. Shoulder matoid arthritis. A radiographic 15-year study. Rev
affections in rheumatoid arthritis. Ann Rheum Dis. Rhum Engl Ed. 1999;66(10):462–6.
1954;13:157–60. 110. Cuende E, Vesga JC, Barrenengoa E, et al. Synovial
96. Neer CS. The rheumatoid shoulder. In: Crubbs RL, cyst as differential diagnosis of supraclavicular
Mitchell NS, editors. The surgical management of mass in rheumatoid arthritis. J Rheumatol.
rheumatoid arthritis. Philadelphia: JB Lippincott; 1996;23(8):1432–4.
1971. p. 117–27. 111. Gibbon WW, Wakefield RJ. Ultrasound in inflamma-
97. Levigne, Ranceschi F. Shoulder arthroplasty. In: tory disease. Radiol Clin N Am. 1999;37:633–51.
Walch, Boileau, editors. Rheumatoid arthritis of 112. Wakefield RJ, Gibbon WW, Emery P. The cur-
the shoulder: radiological presentation and results rent status of ultrasonography in rheumatology.
of arthroplasty. Berlin, Heidelberg: Springer; 1999. Rheumatology (Oxford). 1999;38:195–8.
p. 221–30. 113. Backhaus M, Kamradt T, Sandrock D, Loreck D,
98. Conaghan PG, McQueen FM, Bird P, et al. Update Fritz J, Wolf KJ, et al. Arthritis of the finger joints:
on research and future directions of the OMERACT a comprehensive approach comparing conventional
MRI inflammatory arthritis group. J Rheumatol. radiography, scintigraphy, ultrasound, and contrast-
2011;38(9):2031–3. enhanced magnetic resonance imaging. Arthritis
99. McQueen FM. Magnetic resonance imaging in Rheum. 1999;42:1232–45.
early inflammatory arthritis: what is its role? 114. Backhaus M, Burmester G-R, Gerber T, et al.
Rheumatology (Oxford). 2000;39(7):700–6. Guidelines for musculoskeletal ultrasound in rheu-
100. Narvaez JA, Narvaez J, De Lama E, et al. MR imag- matology. Ann Rheum Dis. 2001;60(7):641–9.
ing of early rheumatoid arthritis. Radiographics. 115. Alasaarela EM, Alasaarela EL. Ultrasound evalua-
2010;30(1):143–63.. (discussion:163-5) tion of painful rheumatoid shoulders. J Rheumatol.
101. Sugimoto H, Takeda A, Hyodoh K. MR imaging 1994;21:1642–8.
for evaluation of early rheumatoid arthritis. Semin 116. Keysser P, Osthus H, Jacobi E. Ultrasound of the
Musculoskelet Radiol. 2001;5(2):159–65. shoulder in patients with rheumatoid arthritis. Ann
102. Cimmino MA, Innocenti S, Livrone F, et al. Dynamic Rheum Dis. 2003;62:519.
gadolinium-enhanced magnetic resonance imaging 117. Sanja MR, Mirjana ZS. Ultrasonographic study of
of the wrists in patients with rheumatoid arthritis can the painful shoulder in patients with rheumatoid
discriminate active from inactive disease. Arthritis arthritis and patients with degenerative shoulder dis-
Rheum. 2003;48(5):1207–13. ease. Acta Rheumatol Port. 2010;35(1):50–8.
103. Hodgson RJ, O’Connor P, Moots R. MRI of rheuma- 118. Nevien EL, Heba K, et al. Value of dynamic sonog-
toid arthritis image quantitation for the assessment raphy in the management of shoulder pain in patients
of disease activity, progression and response to ther- with rheumatoid arthritis. Egypt J Radiol Nucl Med.
apy. Rheumatology (Oxford). 2008;47(1):13–21. 2014;45(4):1171–82.
104. McQueen FM, Stewart N, Crabbe J, Robinson E, 119. Ottaviani S, Gill G, Palazzo E, Meyer O, Dieudé
Yeoman S, Tan PL, et al. Magnetic resonance imag- P. Ultrasonography of shoulders in spondyloarthritis
ing of the wrist in early rheumatoid arthritis reveals and rheumatoid arthritis: a case-control study. Joint
a high prevalence of erosions at four months after Bone Spine. 2014;81(3):247–9.
symptom onset. Ann Rheum Dis. 1998;57(6):350–9. 120. Richette P, Bardin T, Doherty M. An update on the
105. McQueen FM, Stewart N, Crabbe J, Robinson E, epidemiology of calcium pyrophosphate dihydrate
Yeoman S, Tan PL, et al. Magnetic resonance imag- crystal deposition disease. Rheumatology (Oxford).
ing of the wrist in early rheumatoid arthritis reveals 2009;48(7):711–5.
progression of erosions despite clinical improve- 121. McCarty DJ, Hogan JM, Gatter RA, et al. Studies
ment. Ann Rheum Dis. 1999;58(3):156–63. on pathological calcifications in human cartilage.
106. Foley-nolan D, Stack JP, Ryan M, Redmond U, I. Prevalence and types of crystal deposits in the
Barry C, Ennis J, et al. Magnetic resonance imag- menisci of two hundred fifteen cadavers. J Bone
ing in the assessment of rheumatoid arthritis: a com- Joint Surg. 1966;48A:309–25.
parison with plain film radiographs. Br J Rheumatol. 122. Ryan LM, McCarty DJ. Calcium pyrophosphate
1991;31:101–6. crystal deposition disease, pseudogout and articu-
107. Lehtinen JT, Kaarela K, Belt EA, et al. Incidence lar chondrocalcinosis. In: McCarty DJ, Koopman
of glenohumeral joint involvement in seropositive WJ, editors. Arthritis and allied conditions. 13th ed.
rheumatoid arthritis. A 15 year endpoint study. J Philadelphia: Lea and Febiger; 1997. p. 2103–25.
Rheumatol. 2000;27(2):347–50. 123. Resnick D, Niwayama G, Georgen TG, et al. Clinical,
108. Alasaarela E, Suramo I, Tervonen O, et al. Evaluation radiographic and pathologic abnormalities in cal-
of humeral head erosions in rheumatoid arthritis: a cium pyrophosphate dihydrate deposition disease
comparison of ultrasonography, magnetic resonance (CPPD): pseudogout. Radiology. 1977;122:1–15.
imaging, computed tomography and plain radiogra- 124. Martel W, McCarter DK, Solsky MA, et al.
phy. Br J Rheumatol. 1998;37(11):1152–6. Further observation of the arthropathy of calcium
p yrophosphate dihydrate crystal deposition disease. 141. Mizutani H, Ohba S, Mizutani M, et al. Tumoral
Radiology. 1981;141:1–15. calcium pyrophosphate dihydrate deposition
125. Rosenthal AK. Crystals, inflammation, and osteoar- disease with bone destruction in the shoulder.
thritis. Curr Opin Rheumatol. 2011;23(2):170–3. CT and MR findings in two cases. Acta Radiol.
126. Ea HK, Liote F. Advances in understanding calcium- 1998;39(3):269–72.
containing crystal disease. Curr Opin Rheumatol. 142. Richards AJ, Hamilton EBD. Destructive arthropa-
2009;21(2):150–7. thy in chondrocalcinosis articularis. Ann Rheum
127. McCarty DJ. Calcium pyrophosphate dihydrate Dis. 1973;33:196.
crystal deposition disease --1975. Arthritis Rheum. 143. Jacobelli S, McCarty DJ, Silcox DC, et al. Calcium
1976;19(Suppl 3):275–85. pyrophosphate dihydrate crystal deposition in neu-
128. Doherty M, Dieppe P. Clinical aspects of calcium ropathic joints: four cases of polyarticular involve-
pyrophosphate dihydrate crystal deposition. Rheum ment. Ann Intern Med. 1973;79:340–7.
Dis Clin N Am. 1998;14(2):395–414. 144. Beltran J, Marty-Delfaut E, Bencardino J, et al.
129. Resnick D, Utsinger PD. The wrist arthropathy of Chondrocalcinosis of the hyaline cartilage of
“pseudogout” occurring with and without chondro- the knee: MRI manifestations. Skelet Radiol.
calcinosis. Radiology. 1974;113:633–41. 1998;27(7):369–74.
130. Fisseler-Eckhoff A, Muller KM. Arthroscopy and 145. Dufauret-Lombard C, Vergne-Salle P, Simon A,
chondrocalcinosis. Arthroscopy. 1992;8:98–104. Bonnet C, Treves R, Bertin P. Ultrasonography
131. Kanterewicz E, Sanmarti R, Panella D, Brugures in chondrocalcinosis. Joint Bone Spine.
J. Tendon calcifications of the hip adductors in chon- 2010;77(3):218–21.
drocalcinosis: a radiological study of 75 patients. Br 146. Fodor D, Albu A, Gherman C. Crystal-associated
J Rheumatol. 1993;32:790–3. synovitis-ultrasonographic feature, clinical correla-
132. Gerster JC, Baud CA, Lagier R, Boussina I, Fallet tion. Orthop Trumatol Rehabil. 2008;10(2):99–110.
GH. Tendon calcifications in chondrocalcinosis: a 147. Filippucci E, Sedie AD, Riente L, et al. Ultrasound
clinical, radiologic, histologic and crystallographic imaging for the rheumatologist. XLVII. Ultrasound
study. Arthritis Rheum. 1977;20:717–22. of the shoulder in patients with gout and cal-
133. Foldes K, Lenchik L, Jaovisidha S, Clopton P, cium pyrophosphate deposition disease. Clin Exp
Sartoris DJ, Resnick D. Association of gastrocne- Rheumatol. 2013;31(5):659–64.
mius tendon calcification with chondrocalcinosis of 148. Frediani B, Filippou G, Falsetti P, et al. Diagnosis
the knee. Skelet Radiol. 1996;25:621–4. of calcium pyrophosphate dihydrate crystal deposi-
134. Martel W, Champion CK, Thompson GR, Carter tion disease: ultrasonographic criteria proposed. Ann
TL. A roentgenologically distinctive arthropathy in Rheum Dis. 2005;64:638–40.
some patients with the pseudogout syndrome. AJR 149. Hayes CW, Conway WF. Calcium hydroxy-
Am J Roentgenol. 1970;109:587–605. apatite deposition disease. Radiographics.
135. Ryan LM, McCarty DJ. Calcium pyrophosphate 1990;10:1031–48.
crystal deposition disease: pseudogout; articular 150. Codman EA. The shoulder. Boston: Todd; 1934.
chondrocalcinosis. In: McCarty DJ, editor. Arthritis 151. Uhthoff HK, Loehr JW. Calcific tendinopathy of the
and allied conditions. Philadelphia: Lea & Febiger; rotator cuff: pathogenesis, diagnosis, and manage-
1985. p. 1515–46. ment. J Am Acad Orthop Surg. 1997;5(4):183–91.
136. Canhao H, Fonseca JE, Leandro MJ, et al. Cross- 152. Gordon B. Observations on periarthritis calcarea.
sectional study of 50 patients with calcium pyro- AJR. 1957;77:93–108.
phosphate dihydrate crystal arthropathy. Clin 153. Bosworth BM. Calcium deposits in the shoulder and
Rheumatol. 2001;20(2):119–22. subacromial bursitis: a survey of 12,122 shoulders.
137. Ellman MH, Krieger MI, Brown N. Pseudogout JAMA. 1941;116:2477–82.
mimicking synovial chondromatosis. J Bone Joint 154. Selby CL. Acute calcific tendinitis of the hand:
Surg. 1975;57:863–5. an infrequently recognized and frequently mis-
138. Steinbach LS. Calcium pyrophosphate dihydrate diagnosed form of periarthritis. Arthritis Rheum.
and calcium hydroxyapatite crystal deposition dis- 1984;27:337–40.
eases: imaging perspectives. Radiol Clin N Am. 155. Terkeltaub RA, Ginsberg MH. The inflamma-
2004;42(1):185–205.. vii tory reaction to crystals. Rheum Dis Clin N Am.
139. Schumacher HR Jr, Klippel JH, Koopman 1988;14:353–64.
WJ. Calcium pyrophosphate dihydrate crystal depo- 156. Elferink JGR, Deiekauf M. A biochemical study of
sition disease. In: Schumacher HR Jr, Klippel JH, hydroxyapatite crystal induced enzyme release from
Koopman WJ, Primer on the rheumatic disease. neutrophils. Ann Rheum Dis. 1987;46:590–7.
Atlanta Arthritis Foundation; 1993 219–222. 157. Cho Ns LBG, Rhee YG. Radiologic course of the
140. Resnick D, Williams G, Weisman MH, et al. calcific deposits in calcific tendinitis of the shoul-
Rheumatoid arthritis and pseudo-rheumatoid der: does the initial radiologic aspect affect the final
arthritis in calcium pyrophosphate dihydrate crys- results? J Shoulder Elb Surg. 2010;19(2):267–72.
tal deposition disease. Radiology. 1981;140(3): 158. Lee SY, Cheng B, Grimmer-Somers K. The midterm
615–21. effectiveness of extracorporeal shockwave therapy
in the management of chronic calcific shoulder ten- edema mimicking metastatic disease. Skelet Radiol.
dinitis. J Shoulder Elb Surg. 2011;20(5):845–54. 2002;31:359–61.
159. Mouzopoulos G, Stamatakos M, Mouzopoulos D, 174. Hayes CW, Rosenthal DI, Plata MJ, Hudson
et al. Extracorporeal shock wave treatment for shoul- ™. Calcific tendinitis in unusual site associated
der calcific tendonitis: a systematic review. Skelet with cortical bone erosion. Am J Roentgenol.
Radiol. 2007;36(9):803–11. 1987;149:967–70.
160. Marder RA, Heiden EA, Kim S. Calcific tendon- 175. Flemming DJ, Murphey MD, Shekitka KM, Temple
itis of the shoulder: is subacromial decompression HT, Jelinek JJ, Kransdorf MJ. Osseous involvement
in combination with removal of the calcific deposit in calcific tendinitis: a retrospective review of 50
beneficial? J Shoulder Elb Surg. 2011;20(6):955–60. cases. Am J Roentgenol. 2003;181:965–72.
161. Bonavita JA, Dalinka MK, schumacher 176. Chung CBm Gentili A, Chew FS. Calcific tendinosis
HR. Hydroxyapatite deposition disease. Radiology. and periarthritis: classic magnetic resonance imaging
1980;134:621–5. appearance and associated findings. J Comput Assist
162. Bosworth BM. Calcium deposits in the shoulder and Tomogr. 2004;28:390–6.
subacromial bursitis: a survey of 12,122 cases. J Am 177. Farin PU, Jaroma H. Sonographic findings of
Med Assoc. 1941;116:2477–82. rotator cuff calcifications. J Ultrasound Med.
163. Depalma AF, Kruper JS. Long-term study of shoul- 1995;14(1):7–14.
der joints afflicted with and treated for calcific tendi- 178. Bureau NJ. Calcific tendinopathy of the shoul-
nitis. Clin Orthop. 1961;20:61–72. der. Semin Musculoskelet Radiol. 2013;17(1):
164. Mole D, Kempf JF, Gleyze P, Rio B, Bonnomet F, 80–4.
Walch G. Resultat du traitement arthroscopique des 179. Le Goff B, Berthelot JM, Guilot P, Glemarec J,
tendinopathies non rompues, Il: les calcifications. Maugars Y. Assessment of calcific tendonitis of rota-
Rev Chir Orthop. 1993;79:532–41. tor cuff by ultrasonography: comparison between
165. Faure G, Daculsi G. Calcific tendinitis: a review. symptomatic and asymptomatic shoulders. Joint
Ann Rheum Dis. 1983;42:49–53. Bone Spine. 2010;77(3):258–63.
166. Wainner RS, Hasz M. Management of acute calcific 180. McCarty DJ, Halverson PB, Carrera GF, et al.
tendinitis of the shoulder. J Orthop Sports Phys Ther. “Milwaukee shoulder”: association of micro-
1998;27(3):231–7. spheroids containing hydroxyapatite crystals,
167. Loew M, Sabo D, Wehrle M, et al. Relationship active collagenase, and neutral protease with
between calcifying tendinitis and subacromial rotator cuff defects. Arthritis Rheum. 1981;24:
impingement: a prospective radiography and mag- 464–73.
netic resonance imaging study. J Shoulder Elb Surg. 181. Halverson PB, McCarty DJ, Cheung HS, et al.
1996;5(4):314–9. Milwaukee shoulder syndrome: eleven additional
168. Hurt G, Baker CL Jr. Calcific tendinitis of the shoul- cases with involvement of the knee in seven (basic
der. Orthop Clin North Am. 2003;34(4):567–75. calcium phosphate crystal deposition disease).
169. Cahir J, Saifuddin A. Calcific tendonitis of pecto- Semin Arthritis Rheum. 1984;14(1):36–44.
ralis major: CT and MRI findings. Skelet Radiol. 182. McCarty DJ. Arthritis associated with crys-
2005;34(4):234–8. tals containing calcium. Med Clin North Am.
170. Durr HR, Lienemann A, Silbernagl H, et al. Acute 1986;70(2):437–54.
calcific tendinitis of the pectoralis major insertion 183. McCarty DJ. Milwaukee shoulder syndrome.
associated with cortical bone erosion. Eur Radiol. Trans Am Clin Climatol Assoc. 1991;102:271–83..
1997;7(8):1215–7. (discussion:283-4)
171. Ikegawa S. Calcific tendinitis of the pectoralis major 184. Garcia GM, McCord GC, Kumar R. Hydroxyapatite
insertion. A report of two cases. Arch Orthop Trauma crystal deposition disease. Semin Musculoskelet
Surg. 1996;115(2):118–9. Radiol. 2003;7(3):187–93.
172. Zubler C, Mengiardi B, Schmid MR, et al. MR 185. Forster CJ, Oglesby RJ, Szkutnik AJ, Roberts
arthrography in calcific tendinitis of the shoulder: JR. Positive alizarin red clumps in Milwaukee shoul-
diagnostic performance and pitfalls. Eur Radiol. der syndrome. J Rheumatol. 2009;36(12):2853.
2007;17(6):1603–10. 186. Epis O, Caporali R, Scire CA, et al. Efficacy of
173. Yang I, Hayes CW, Biermann JS. Calcific tendini- tidal irrigation in Milwaukee shoulder syndrome. J
tis of the gluteus medius tendon with bone marrow Rheumatol. 2007;34(7):1545–50.
Preoperative Planning
and Postoperative Imaging 11
of Shoulder Arthroplasty
Jonelle Petscavage-Thomas
11.1 Pertinent Imaging Anatomy humeral head and the undersurface of the
acromion. This space is normally greater than
The glenohumeral joint is the articulation 7 mm in diameter [4].
between the humeral head and glenoid fossa of Radiographic evaluation of the glenohumeral
the scapula. The humeral head is normally angled joint space and subtle humeral head migration of
130–140° superomedial to the long axis of the instability are best seen on the Grashey radio-
humeral shaft with 30° of retroversion [1]. The graphic view (Fig. 11.1c). The Grashey view is
lateral protuberance of the humeral head is the performed with the patient rotated posteriorly
greater tuberosity. This is the site of attachment 35–45° with the plane of the scapula parallel to
of the supraspinatus, infraspinatus, and teres the film cassette [5]. The normal glenohumeral
minor rotator cuff tendons. The greater tuberosity joint space is 3–6 mm [6].
is best seen on externally rotated AP radiographs
(Fig. 11.1a) [2]. The lesser tuberosity is a small
tubercle anteroinferior to the greater tuberosity 11.2 Pathological Conditions
and site of the subscapularis tendon attachment.
It is best seen on internally rotated radiographs 11.2.1 Definition
(Fig. 11.1b) [2]. The greater and lesser tuberosi-
ties are separated by the bicipital groove. The Approximately two-thirds of shoulder joint
humeral head is covered by articular cartilage. replacements are placed for glenohumeral joint
The glenoid fossa, or cavity, is a pear-shaped osteoarthritis [7]. Osteoarthritis, also known as
articular surface of the lateral scapula [3] degenerative arthritis, is a gradual, progressive,
(Fig. 11.1). The fossa accommodates a broad and mechanical process of the glenohumeral
range of motion of the humeral head. The fibro- articular cartilage, bone, and capsule. As the pro-
cartilaginous glenoid labrum and synovial-lined cess progresses, there is loss of normal load-
joint capsule with glenohumeral ligaments aug- bearing surfaces, resulting in pain and disability
ment and stabilize the osseous glenoid. The myo- [8]. Primary osteoarthritis has no specific cause
tendinous rotator cuff dynamically stabilizes the while secondary osteoarthritis may result from
glenohumeral joint [3]. The myotendinous rota- shoulder trauma, chronic glenohumeral joint dis-
tor cuff occupies the space between the superior location, and instability, infection, congenital
abnormalities, or chronic rotator cuff tears [9].
This last type of secondary osteoarthritis is also
J. Petscavage-Thomas (*)
Department of Radiology, Penn State Milton termed “cuff-tear arthropathy.” The hypothesis is
S. Hershey Medical Center, Hershey, PA, USA that the rotator cuff tears result in leakage of joint

248 J. Petscavage-Thomas
a b c
Fig. 11.1 Normal shoulder anatomy. (a) AP externally of the left shoulder shows the lesser tuberosity (arrow). (c)
rotated radiograph of the left shoulder shows the greater Grashey view of the left shoulder shows normal glenohu-
tuberosity (black arrow) and pear-shaped articular glenoid meral joint space
fossa (white arrow). (b) AP internally rotated radiograph
a b
Fig. 11.2 Osteoarthritis. (a) Grashey view of the right (black arrow). (b) AP view of the right shoulder shows
shoulder shows narrowing of the glenohumeral joint space narrowed acromiohumeral distance (black arrow) with
(white arrow). There is subchondral sclerosis of the artic- superior subluxation of the humeral head
ular surfaces with subchondral cysts and osteophytes
fluid and loss of intra-articular joint pressure. 11.2.2 Radiographic and CT Findings
This results in microinstability of the glenohu-
meral joint and excessive wear and tear on the Radiographs remain the primary imaging modal-
articular cartilage [10]. ity for diagnosis and assessment of glenohumeral
Other indications for shoulder arthroplasty are joint osteoarthritis. Radiographs demonstrate the
trauma, including proximal humeral fractures hallmarks of osteoarthritis, namely osteophyte
and Bankart fractures, rheumatoid arthritis, avas- formation, subchondral sclerosis, subchondral
cular necrosis, and focal cartilage defects of the cystic change, and joint-space narrowing (best
humeral head. seen on the Grashey view) (Fig. 11.2a). Massive
11 Preoperative Planning and Postoperative Imaging of Shoulder Arthroplasty 249
cuff tear arthropathy is suggested by a narrowed shoulders require grafting due to poor bone stock
acromiohumeral distance (<7 mm) (Fig. 11.2b) [14, 15]. Patients with glenohumeral joint osteo-
[4] with superior subluxation of the humeral head arthritis often have a retroverted glenoid due to
on AP radiographs. Additional findings include posterior glenoid rim erosions [16]. Patients
an exaggerated groove between the greater tuber- with rheumatoid arthritis have also been shown
osity and humeral articular surface and remodel- to have a retroverted glenoid [17]. It is impera-
ing of the undersurface of the acromion. The tive for surgeons to correct retroversion to
most specific findings are superior migration of prevent the complications of radiolucency, loos-
the humeral head with subcortical cystic change ening, humeral head dislocation, and glenoid
of the greater tuberosity [11, 12]. wear [18–20]. Thus preoperative measurements
Rheumatoid arthritis, another common indica- are useful to determine the amount of anterior
tion for shoulder arthroplasty, is seen on radio- reaming or bone grafting needed to correct
graphs as bilateral symmetric glenohumeral retroversion.
joint-space narrowing. Osseous erosions are most The glenoid is assessed in several ways. First,
common at the superomedial aspect of the axillary radiographs or axial computed tomogra-
humeral head and acromioclavicular joint. Bones phy (CT) images are used to determine glenoid
are generally osteoporotic seen [13]. morphology using the Walch classification
Adequate osseous support for a glenoid com- (Fig. 11.3) [21]. Type A morphology is a centered
ponent in total shoulder arthroplasty is critical as humeral head with (A1) minor or (A2) major gle-
prior studies have shown that up to 20% of noid erosions. Type B morphology is a posteriorly
Fig. 11.3 Author’s Type A = Centered humeral head

illustration of the Walch
classification system of
glenoid morphology
A1 A2
Minor erosion Major erosion
Type B = Posteriorly subluxed humeral head
B1 B2
Posterior narrowing Posterior + Retroverted

osteophytes, sclerosis rim erosion glenoid
Type C = Glenoid retroversion

>25° regardless of erosion
C
subluxed humeral head with (B1) posterior joint- coracoid, middle, and lower portions [17]. At the
space narrowing and osteophytes or (B2) posterior upper base, the maximum AP diameter and width
rim erosions and retroversion. Type C is greater of the scapular neck are measured (Fig. 11.6a).
than 25° retroversion. Comparing the two modali- The distance between these two is the medial dis-
ties, axillary radiographs have poor inter- and placement, which reflects the glenoid depth. At
intraobserver reproducibility and have been shown the middle and lower glenoid levels, the amounts
to overestimate the degree of retroversion [22]. of supported bone and unsupported anterior and
Thus, CT is preferred for reproducibility in
measurement of glenoid retroversion. On
2-dimensional (2D) CT, version is defined as the
angle formed between a line drawn from the
medial border of the scapula to the center of the
glenoid and the line perpendicular to the face of
the glenoid on the axial slice at or just below the
tip of the coracoid of the scapula (Fig. 11.4) [23].
Recently, studies have shown 3D CT to be more
accurate in detecting posterior glenoid erosion
and retroversion [24–26]. To assess retroversion,
draw a vertical line on the 3D surface of the gle-
noid face, centered in the AP direction. A trans-
verse 2D plane is generated perpendicular to the
midpoint of the vertical line passing through the Fig. 11.4 Axial CT in bone windows of the right shoul-
scapular axis (center of glenoid and tip of scapu- der shows assessment of glenoid retroversion. The angle
lar spine) to obtain an image for angle measure- is formed between a line perpendicular (black) to a line
ment (Fig. 11.5) [11]. (yellow) drawn from the medial border of the scapula to
the glenoid center and the line (purple) along the glenoid
Preoperative CT is also used to assess glenoid face. In this patient, the glenoid is retroverted by 10°. Also
bone stock. On axial CT images, the glenoid is seen is severe narrowing of the glenohumeral joint space
measured at the level of the upper base of the with subchondral sclerosis and subchondral cystic change
a b
Fig. 11.5 3D CT assessment of glenoid retroversion. (a) dicular to the midpoint of the vertical line (purple) to pass
3D volume-rendered image of the glenoid face where a through the scapular axis. (b) The version angle is then
vertical line (green) is drawn centered in the anteroposte- applied at the level of the transverse plane using the
rior direction. A transverse 2D plane is generated perpen- Friedman technique for the 2D CT
posterior bone are measured (Fig. 11.6b). base and most lateral part of the greater tuberos-
Additionally, the medial displacement is mea- ity (Fig. 11.7a) [27]. Iannotti showed that LHO
surement at these levels. Both osteoarthritis and correlates with both humeral head size and
rheumatoid shoulders have been shown to have moment arm [28]. Preoperative LHO should be
more unsupported bone with greater AP diame- noted in case it requires surgical correction.
ters and decreased medial displacement. In rheu- Plain films are typically still utilized for LHO
matoid arthritis, the significance is that undetected assessment but have a projection error of up to
glenoid erosions could lead to medial placement 50% [29]. Axial CT has excellent interobserver
of a glenoid component with inaccurate soft- reliability and intraobserver reproducibility [30].
tissue tension. On CT, LHO is the distance between the medial
A final radiographic or CT preoperative edge of the base of the coracoid process and the
assessment involves lateral humeral offset most lateral aspect of the greater tuberosity
(LHO). This is the distance between the coracoid (Fig. 11.7b).
a b
Fig. 11.6 CT assessment of glenoid bone stock. (a) Axial middle glenoid shows measurements of unsupported bone
image of a left shoulder at the level of the upper glenoid anteriorly (AU) and posteriorly (PU) and supported bone
base shows maximum AP diameter (blue line) and width (S) as well as glenoid depth (D). Same measurements are
of scapular neck (yellow line). Distance between these performed at the lower glenoid level
(white line) is the glenoid depth. (b) Axial image of the
a b
Fig. 11.7 Lateral humeral offset. (a) AP radiograph of shoulder demonstrates offset as distance between the
the left shoulder shows lateral humeral offset as distance medial edge of coracoid base and lateral part of greater
(white line) between coracoid base and most lateral part tuberosity (white line)
of the greater tuberosity. (b) Axial CT image of the same
11.2.2.1 Ultrasound Findings Finally, since the deltoid muscle is used as the pri-
Recognition of rotator cuff tears is important in sur- mary-level arm in RTSA, dehiscence and presence
gical planning. In the absence of tear, the patient of fatty atrophy should be reported if present.
may be a candidate for an anatomic total shoulder
arthroplasty (ATSA). Irreparable tears or massive 11.2.2.2 MR Findings
tears require a reverse total shoulder arthroplasty Although the accuracy of ultrasound is compara-
(RTSA). Although radiographs can demonstrate ble to MR, it cannot depict glenohumeral arthrosis
findings of massive rotator cuff tear, they do not and cartilage defects. The bone stock and retrover-
depict the degree of associated muscle atrophy or sion with Walch classification of the glenoid can
retraction and are not as sensitive as other modali- also be performed with MR. Similar to ultrasound,
ties. In equivocal cases, recognition of a rotator cuff presence of full- versus partial- thickness tears,
tear can be performed with ultrasound. Ultrasound degree of muscle atrophy as staged by Goutallier,
has been shown to have similar accuracy compared and deltoid muscle status are important findings to
to magnetic resonance (MR) imaging for detection report for preoperative assessments.
of supraspinatus (91.1%), infraspinatus (84.4%),
and subscapularis tears (77.8%) [31]. Direct signs
of full-thickness tear include non-visualization of 11.3 Postoperative Imaging
the tendon and hypoechoic discontinuity of the ten-
don. Indirect signs of a full-thickness tear include 11.3.1 Normal Appearance
the double-cortex sign, sagging peribursal fat sign,
compressibility, and muscle atrophy [32]. Well- 11.3.1.1 Anatomic Total Shoulder
defined hypoechoic or anechoic defects in the ten- Arthroplasty
don involving only the bursal or articular surface Anatomic total shoulder arthroplasty (ATSA)
indicate a partial-thickness tear. Adjacent cortical replaces both glenoid and humeral articular surfaces.
pitting and irregularity may be seen in the humeral The humeral component is a minimally constrained
head. Degree of muscle atrophy should be reported implant with a spherical metal articular surface and
on to provide a full assessment of reparability. a cemented or press-fit metal stem (Fig. 11.8).
a b
Fig. 11.8 Anatomic total shoulder arthroplasty. (a) AP tered in the humeral shaft. The glenoid component (white
and (b) lateral radiographs of the right shoulder show the arrow) is radiolucent with radiopaque markers for
humeral component of the arthroplasty (black arrow) cen- identification
The humeral heads are anatomic or adaptable as of radiolucency are reported with pegged
they can be adjusted as referenced to the humeral implants [37]. However, keeled components are
stem in both anteroposterior and mediolateral direc- required for patients with poor glenoid bone
tions and allow for various degrees of humeral head stock [33].
inclination [33]. Cement is used in patients with Another trend is ream and run arthroplasty of
poor bone stock, such as rheumatoid arthritis or the glenoid. Here, the glenoid is reamed to have a
osteoporosis. An extended-coverage humeral head stabilizing concavity and maximum glenohu-
design (CTA) is an option for patients with rotator meral contact area. It has been shown that the
cuff tears and narrowed acromial-humeral distance. reamed glenoid bone forms new fibrocartilage.
The head component extends more laterally to cover This procedure is selected for patients hoping to
the greater tuberosity, thereby decreasing impinge- avoid the risk of glenoid component wear and
ment [34, 35]. who are willing to participate in a 2-year daily
A new trend in ATSA is the use of stemless exercise rehabilitation program [38].
humeral components (Fig. 11.9). The goal is to Normal postoperative imaging assessment
preserve humeral bone stock, decrease humeral includes AP internal and external rotation views,
stem-associated complications, and be less inva- Grashey or scapular y views, and axillary views.
sive. Preliminary reports show radiographic sta- The humeral stem should be centered in the
bility without migration or subsidence at 2- to humeral shaft as more lateral or medial position
3-year minimum follow-up [36]. results in altered stress distribution, cortical bone
The glenoid component of ATSA is comprised resorption, and rotator cuff insufficiency [39].
of radiolucent polyethylene fixed with poly- The humeral component height should be
methyl methacrylate. The component is attached between 2 and 5 mm above a line perpendicular
to bone by either a central keel or two or more to the greater tuberosity (Fig. 11.10). The glenoid
pegs, which have radiopaque markers for identi- component should be centered with the bone with
fication on radiographs (Fig. 11.8). Lower rates no surrounding radiolucency. Some components
Fig. 11.9 Anatomic total shoulder arthroplasty. AP Fig. 11.10 Humeral component height. Distance
radiograph of the right shoulder show a stemless humeral between the greater tuberosity and humeral head should
component (arrow) and polyethylene glenoid component be 2–5 mm (white line)
have central pegs packed with bone graft for bio- Partial humeral head resurfacing is indicated
logic incorporation. Sclerosis around the central for focal chondral defects as an alterative
peg is a normal finding of graft healing and treatment to autograft or allograft implantation or
incorporation. microfracture. It is also used for patients with
focal erosions, such as rheumatoid arthritis [43].
11.3.1.2 Hemiarthroplasty The prosthesis consists of an articular cobalt-
Hemiarthroplasty (HA) is replacement of only chromium alloy surface component with small
the humeral articular surface. This usually con- central peg mated with tapered titanium-alloy-
sists of placement of the stemmed metal cannulated screw/post. Similar to total humeral
humeral component of ATSA (Fig. 11.11a). HA head resurfacing, the cap should be flush against
is indicated for severe proximal humerus frac- bone and centered on the glenoid on the lateral
tures, arthritis in which glenoid bone stock is view (Fig. 11.11c).
inadequate to support a prosthesis, and isolated
osteonecrosis or osteoarthritis of the humerus 11.3.1.3 Reverse Total Shoulder
[34, 35]. Arthroplasty
Two newer hemiarthroplasty options are RTSA is a semiconstrained prosthesis designed
humeral head resurfacing and partial humeral to stabilize the glenohumeral center of rotation
head resurfacing. Resurfacing was introduced as by moving it more distally and medially,
a cementless, humeral head replacement in young thereby improving length and contraction of the
or athletic patients with arthritis, avascular necro- deltoid muscle for motion control over the
sis, instability, or rotator cuff arthropathy [39]. In shoulder [44, 45]. RTSA consists of a metal
resurfacing, a humeral osteotomy is not per- baseplate, called the metaglene, a glenosphere
formed and bone stock is preserved for future ball, and a humeral socket (Fig. 11.12) [46].
revisions [40, 41]. The component is a metal- The metaglene is press-fit with a flat or convex
alloy cap with grooved cruciate stem with a radius of curvature. It is fixed to the glenoid
hydroxyapatite on growth surface for attaining with a central post, keel, or central screw. An
rotational stability [42]. On radiographs the cap additional 1–6 peripheral non-locking or vari-
should be flush with the articular surface and ability angled locking screws are implanted for
humeral head should remain centered on the gle- compressive fixation strength [47]. The gleno-
noid (Fig. 11.11b). sphere is a round metal ball attached to the
a b c
Fig. 11.11 Hemiarthroplasty. (a) AP radiograph of the metal cap (black arrow) and stem of a humeral head resur-
left shoulder shows use of the humeral component of facing arthroplasty. (c) AP radiograph of the right shoul-
ATSA in hemiarthroplasty. Note no glenoid insert or com- der shows a partial humeral head resurfacing
ponent. (b) AP radiograph of the left shoulder shows the
a b
Fig. 11.12 Reverse total shoulder arthroplasty. (a) Grashey and (b) lateral views of the right shoulder show the meta-
glene (arrow), glenosphere (G), and humeral stem components (H) of a reverse total shoulder arthroplasty
metaglene. A radiolucent polyethylene insert

sits in the humeral component proximal
cup-shaped portion as an articulation between
the glenosphere and humeral component.
Normal postoperative imaging assessment
should be performed with AP, scapular Y, and
axillary radiographs. The metaglene should be
flush to the glenoid. The glenosphere should be
flush to the metaglene. The glenosphere should
align with the humeral cup, though thickness can
vary depending on polyethylene insert [46]. The
humeral socket shaft angle varies between 130
and 150°. However, more varus designs may be
used to match native anatomic head neck angle
and minimize humeral component notching of
the inferior scapula [48].
11.3.1.4 Oncologic Humeral

Prostheses
Oncologic humeral components are placed in
patients after surgical removal of benign or
malignant neoplasms or severe proximal humeral
fractures. They may or may not allow for recon-
struction of the rotator cuff for additional joint
stability. In rotator cuff reconstruction, suture
holes are present in the prosthesis for direct
attachment or a nylon/Dacron mesh capsulo-
Fig. 11.13 Oncologic shoulder arthroplasty. AP radio-
plasty for indirect attachment [49]. The prosthe-
graph of the left shoulder shows a long-stemmed humeral
ses consist of an all-metal long-stemmed humeral component with resection of a large amount of humeral
component (Fig. 11.13). bone stock in a patient with benign bone neoplasm
11.3.2 Complications Although less commonly a site of loosening,

development of progressive radiolucency or
11.3.2.1 ATSA radiolucency >2 mm around the humeral compo-
The most common complication of ATSA is nent is abnormal (Fig. 11.15a, b). Radiolucency
glenoid component loosening, occurring in up may reflect aseptic loosening, small particle dis-
to one-third of patients [50]. Glenoid compo- ease, or infection. Radiolucency is reported
nent loosening is seen on radiographs as according to the system of Gruen [53](Fig.
radiolucency at the bone-cement interface
11.15c, d), which divides the humerus into eight
(Fig. 11.14a). CT is superior to radiographs regions. Small particle disease occurs when there
for showing osteolysis, showing 19 more is wear of the polyethylene components, result-
lesions than radiographs in a recent study [51]. ing in a macrophage response with osteolysis.
Thus, CT is recommended when there is suspi- Presence of the additional findings of periosti-
cion of particle disease (Fig. 11.14b) and tis, joint effusion, and soft-tissue swelling sug-
radiographs are negative. The Lazarus classifi- gests that the radiolucency may be due to deep
cation system is used for radiographic and CT infection (Fig. 11.16a). The incidence of infec-
description of radiolucency of pegged glenoid tion is 0–3.9% and most often due to
components (Fig. 11.14c) [37]. The Franklin Staphylococcus aureus and Propionibacterium
classification is used to describe radiolucency acnes [54]. Cross-sectional imaging is helpful to
surrounding keeled glenoid components further evaluate for joint effusion, soft-tissue col-
(Fig. 11.14d) [52]. lections, bone marrow edema, and periostitis
a b
Fig. 11.14 Glenoid component loosening. (a) Grashey osteolysis (arrow). (c) Lazarus classification of pegged
radiograph of a left shoulder ATSA shows radiolucency glenoid radiolucency. G = glenoid. Yellow indicates
surrounding the pegged components (arrows), consistent radiolucency. (d) Franklin classification of keeled gle-
with polyethylene wear. (b) Axial CT image shows radio- noid radiolucency. G = glenoid. Yellow indicates
lucency surrounding the glenoid component and areas of radiolucency
Fig. 11.14 (continued) c Grade 0 Grade 1 Grade 2
G G
G
Grade 3
Grade 4 Grade 5
G
G G
d
Grade 0 Grade 1
Grade 2
G G
G
Grade 3
Grade 4 Grade 5
G
G G
(Fig. 11.16b). Treatment of infected shoulder Intraoperative periprosthetic fractures occur

arthroplasty is explantation of the prosthesis and in 1.2% of primary ATSA [57]. Displaced frac-
placement of an antibiotic-impregnated spacer tures of the tuberosity (Region 1) are treated with
with cement and stabilized by a Steinmann pin suture fixation of the humeral implant. Region 2
(Fig. 11.16c). fractures involve the humeral metaphysis, and are
A mimic of radiolucency is stress shielding, treated with cerclage fixation with autologous
which occurs in 9% of ATSA and HA. Stress bone grafting. A longer stemmed humeral com-
shielding is the long-term adaption of the peri- ponent may be placed for fractures of the proxi-
prosthetic bone to stresses induced by the humeral mal, mid, or distal humeral diaphysis (Regions 3
component [55]. It is a risk factor for peripros- and 4). Postoperative fractures (Fig. 11.15a) typi-
thetic fracture and aseptic loosening. It appears cally occur due to trauma, at a low rate of 1.6–
as cortical thinning and increased osteopenia, 2.4% [58]. Imaging report should include
typically in the region of the greater tuberosity presence of underlying radiolucency and involve-
[56] (Fig. 11.17). ment of the stem.
a b
c d
Fig. 11.15 Humeral component radiolucency. (a) Lateral fracture (arrow) through an area of radiolucency. (b)
radiograph of a right shoulder hemiarthroplasty shows Grashey radiograph of a right ATSA shows focal osteoly-
radiolucency greater than 2 mm (arrowhead) around the sis (arrow). (c) AP and (d) lateral radiographs show eight
humeral component and small anterior periprosthetic zones of radiolucency according to Gruen classification
a b c
Fig. 11.16 Infection. (a) Grashey image of a right total glenohumeral joint effusion (arrowhead). This patient’s
shoulder arthroplasty shows focal erosive change along the synovial culture showed bacterial infection. (c) AP image
proximal humerus (arrow), concerning for infection. (b) post-explanation of a left total shoulder arthroplasty shows
CT axial image of the right shoulder demonstrates a large antibiotic-impregnated cement spacer and pin
Another complication is subsidence, which

is axial settling of the humeral component. This
is seen on radiographs as a change in vertical
distance between the height of the humeral
component and the line perpendicular to the
greater tuberosity [59](Fig. 11.18a). Abnormal
vertical distance may present as narrowing of
the acromial humeral distance with superior
migration of the humerus (Fig. 11.18b) and
suggests new rotator cuff tear, overstuffing
from too large of a humeral head component, or
subacromial impingement related to acromial
spurs [56].
During surgery for shoulder arthroplasty, the
subscapularis tendon is divided to allow access to
the glenohumeral joint [60]. Postoperative tears can
lead to anterior instability, loss of active arm motion,
Fig. 11.17 AP radiograph of the left shoulder in a patient and loosening of the glenoid component [60].
with an anatomic total shoulder arthroplasty shows focal Primary radiographic finding of subscapularis tear
osteopenia of stress shielding is anterior subluxation of the humerus on the
a b
Fig. 11.18 Abnormal vertical distance. (a) AP radio- meral joint consistent with glenoid component loosening.
graph of a left total shoulder arthroplasty shows abnormal (b) AP radiograph of a right shoulder hemiarthroplasty
vertical distance with settling of the humeral component shows superior subluxation of the humeral component
(arrow), consistent with subsidence. The radiopaque gle- (arrow) concerning for new rotator cuff tear
noid marker is also inferiorly dislocated into the glenohu-
a b c
Fig. 11.19 Rotator cuff tear. Lateral radiograph of a the subscapularis tendon (arrow), confirming postopera-
patient with a right ATSA shows anterior subluxation of tive tear. (c) Coronal CT arthrogram image shows contrast
the humeral component in respect to the glenoid. (b) in a defect (arrow) of the infraspinatus tendon
Transverse ultrasound image shows hypoechoic defect in
axillary view (Fig. 11.19a). Subluxation of the

humeral head is classified as absent, slight (transla-
tion <25%), moderate (25–50%), or severe (>50%)
[56]. Ultrasound imaging is useful to detect focal
hypoechoic defects or full tendon tears (Fig. 11.19b)
as it is not limited by metallic susceptibility artifact.
CT arthrography can also be used to assess rotator
cuff integrity. Although less common, postoperative
tearing of the supraspinatus and infraspinatus
(Fig. 11.19c) may occur and is seen as narrowing of
the acromiohumeral distance. Ultrasound and CT
arthrography are preferred for further evaluation of
the tear extent, retraction, and associated atrophy.
In addition to the above complications, onco-
logic humeral components are at risk of failure of
allograft incorporation, large areas of heterotopic
ossification formation, and tumor recurrence. Fig. 11.20 Hemiarthroplasty complication. Axial CT of
the left shoulder in a patient with a hemiarthroplasty
11.3.2.2 Hemiarthroplasty shows central glenoid erosions and remodeling
A unique complication to hemiarthroplasty is
development of glenoid erosions and progressive is progressive glenohumeral arthritis and ero-
glenohumeral arthritis, occurring in up to 64% of sions [62]. A more recent study of 20 shoulders at
patients (Fig. 11.20) [34]. Other humeral a mean follow-up of 32.7 months found no radio-
component-related complications are similar to graphics complications [63].
those described for ATSA.
The most common reported complication of 11.3.2.3 RTSA
humeral head resurfacing is superior migration of There are several unique complications to
the humeral head on AP imaging, reported in up to RTSA. Inferior scapular notching (Fig. 11.22) has
47% of patients [61]. Other complications include been reported to occur in 53–67% of cases,
development of glenohumeral arthritis (Fig. 11.21), although more recent design revisions and varus
infection, osteolysis, arthrofibrosis, subscapularis placement have decreased the incidence [64, 65].
tendon rupture, periprosthetic fracture, instability Notching occurs when the humeral socket
with subluxation, and loosening [39, 62]. impinges the inferior scapula as it articulates with
Similar to anatomic hemiarthroplasty and full the glenosphere [66]. Notching is associated with
humeral head resurfacing, the most common poorer clinical outcomes and premature baseplate
complication of partial humeral head resurfacing failure [65, 66]. Inferior scapular notching is
a b
Fig. 11.21 Glenohumeral arthritis post-resurfacing. (a) larly posteriorly, with subchondral sclerosis in a patient
Grashey radiographs and (b) axial CT arthrogram images with left humeral head resurfacing
show severe glenohumeral joint-space narrowing, particu-
a b
Fig. 11.22 Inferior scapular notching. (a) AP radiograph of a right shoulder RTSA shows notching of the inferior
scapular (arrow), better seen on (b) coronal CT image
graded according to the classification of Sirveaux Anterior dislocation occurs in up to 20% of

et al. A defect only involving the pillar is grade 1 cases and is the most common early postopera-
severity. Grade 2 severity is present if the defect tive complication [46]. Unique to the RTSA, the
contacts the inferior baseplate screw, grade 3 if the humeral component dislocates in the anterior-
notch extends over the inferior screw, and grade 4 superior direction due to pull of the deltoid mus-
if the notch extends under the baseplate [67]. cle (Fig. 11.23) [46].
a c
Fig. 11.23 Dislocation. (a) AP and (b) scapular Y view radiographs of a left shoulder RTSA show anterosuperior displace-
ment of the humeral component of a RTSA. (c) Axial and (d) sagittal CT images confirm anterosuperior position
Another unique complication of RTSA is acro- acromion just posterior to the AC joint (2.5%).
mial fracture (Fig. 11.24), occurring in 5–6.9% of Type III fractures involve the posterior acromion
patients [68]. On radiographs, these fractures may or scapular spine. Acromial insufficiency fracture
appear initially as subtle periosteal reaction and is another unique complication, possibly resulting
increased sclerosis. These tend to occur in patients from lengthening of the arm and increased tension
with preexisting stiff arthritis with increased of the deltoid [71].
stress as glenohumeral motion increases after sur- Rates of infection for RTSA have recently
gery. For unclear cases, CT can detect subtle frac- been shown to be similar to ATSA at 2–3% [72].
tures and sclerosis related to chronic stress. Imaging findings of infection are similar to
Scapular fractures occur in three patterns [69]. RTSA, including radiolucency, periostitis, and/or
Type I are small avulsion fractures in the anterior joint effusion and soft-tissue swelling.
acromion near to or including the footprint of the Other complications of RTSA include
coracoacromial ligament (2% incidence) [70]. mechanical dismantling or fracture of the pros-
Type II fractures propagate through the anterior thesis (Fig. 11.25a), glenosphere disengagement
Fig. 11.24 Acromial

fracture. (a) Axial and a b
(b) sagittal CT images
of a right shoulder
RTSA show fracture line
(arrowhead) through the
acromion
a b
Fig. 11.25 RTSA complications. (a) AP radiograph of a glenosphere to the baseplate (black arrow posteriorly
right RTSA shows intra-articular metaglene-glenosphere compared to narrower space anteriorly) consistent with
migration. (b) Lateral radiograph of a left reverse total glenosphere unseating
shoulder arthroplasty shows asymmetric attachment of the
(3.2%) (Fig. 11.25b), aseptic loosening with or 8. Millett PJ, Gobezie R, Boykin R. Shoulder osteo-
arthritis: diagnosis and management. Am Fam
without intra-articular metaglene migration, and Physician. 2008;78(5):605–11.
subclinical neuropathy [66]. Subclinical neurop- 9. Kerr R, Resnick D, Pineda C, Haghighi P. Osteoarthritis
athy occurs more frequently with RTSA due to of the glenohumeral joint: a radiologic-pathologic
surgical dissection, exuberant retraction, and/or study. AJR Am J Roentgenol. 1985;144(5):967–72.
10. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthrop-
arm positioning [73]. MR may demonstrate athy. J Bone Joint Surg Am. 1983;65:1232–44.
increased signal on fluid-sensitive sequences 11. Kaneko K, Mouy EH, Brunet ME. Massive rotator
within the affected portion of the brachial plexus cuff tears. Screening by routine radiographs. Clin
and musculature. Imaging. 1995;19:8–11.
12. De Smet AA, Ting Y. Diagnosis of rotator cuff
tear on routine radiographs. J Can Assoc Radiol.
1977;28:54–7.
11.4 Conclusion 13. Resnick D, Niwayama G. Rheumatoid arthritis. In:
Resnick D, editor. Diagnosis of bone and joint dis-
orders, vol 2. Philadelphia, PA: Saunders; 1995.
With the increasing implantation of shoulder p. 866–970.
prostheses and innovations in hardware design, 14. Barrett WP, Franklin JL, Jackins SE, Wyss CR,
radiologists will encounter more preoperative Matsen FA III. Total shoulder arthroplasty. J Bone
and postoperative imaging. Glenoid loosening Joint Surg Am. 1987;69-A:865–72.
15. McCoy SR, Warren RF, Bade HA, Ranawat CS, Inglis
remains the most common complication of AE. Total shoulder arthroplasty in rheumatoid arthri-
ATSA, while glenoid erosions and progressive tis. J Arthroplast. 1989;4:105–13.
glenohumeral osteoarthritis are most commonly 16. Raymond AC, McCann PA, Sarangi PP. Magnetic
seen with HA. Unique complications of RTSA resonance scanning vs. axillary radiography in the
assessment of glenoid version for osteoarthritis. J
include inferior scapular notching, early disloca- Shoulder Elb Surg. 2013;22:1078–83.
tion, and scapula fractures. 17. Mullaji AB, Beddow FH, Lamb GHR. CT measure-
ment of glenoid erosion in arthritis. J Bone Joint Surg
(Br). 1994;76-B:384–8.
18. Sabesan V, Callanan M, Ho J, Iannotti JP. Clinical and
References radiographic outcomes of total shoulder arthroplasty
with bone graft for osteoarthritis with severe glenoid
1. Jeong J, Bryan J, Iannotti JP. Effect of a variable pros- bone loss. J Bone Joint Surg Am. 2013;95(14):1290–6.
thetic neck-shaft angle and the surgical technique on 19. Keller J, Bak S, Bigliani LU, Levine WN. Glenoid
replication of normal humeral anatomy. J Bone Joint replacement in total shoulder arthroplasty.
Surg Am. 2009;91(8):1932–41. Orthopedics. 2006;29(3):221–6.
2. Hill HA, Sachs MD. The grooved defect of the 20. Neyton L, Walch G. Nov’e-Josserand L, Edwards
humeral head: a frequently unrecognized c omplication TB. Glenoid corticocancellous bone grafting after gle-
of dislocations of the shoulder joint. Radiology. noid component removal in the treatment of glenoid
1940;35(6):690–700. loosening. J Shoulder Elb Surg. 2006;15(2):173–9.
3. Sheehan SE, Gaviola G, Gordon R, Sacks A, Shi LL, 21. Walch G, Badet R, Boulahia A, Khoury A. Morpho
Smith SE. Traumatic shoulder injuries: a force mech- logic study of the glenoid in primary glenohumeral
anism analysis–glenohumeral dislocation and insta- osteoarthritis. J Arthroplast. 1999;14(6):756–60.
bility. AJR Am J Roentgenol. 2013;201(2):378–93. 22. Nyffeler RW, Jost B, Pfirrmann CW, Gerber
4. Saupe N, Pfirrmann CWA, Schmid MR, et al. C. Measurement of glenoid version: conventional
Association between rotator cuff abnormali- radiographs versus computed tomography scans. J
ties and reduced acromiohumeral distance. AJR. Shoulder Elb Surg. 2003;12(5):493–6.
2006;187(2):376–82. 23. Friedman RJ, Hawthorne KB, Genez BM. The
5. Sanders T, Jersey SL. Conventional Radiography of use of computerized tomography in the measure-
the Shoulder. Semin Roentgenol. 2005;40(3):207– ment of glenoid version. J Bone Joint Surg Am.
22.. Review 1992;74(7):1032–7.
6. Merrill V. Shoulder Girdle. In: Ballinger PW, editor. 24. Hoenecke HR Jr, Hermida JC, Flores-Hernandez C,
Merrill’s atlas of radiographic positions and radio- D’Lima DD. Accuracy of CT-based measurements
graphic procedures, vol. 1 (ed 6). St. Louis, MO: of glenoid version for total shoulder arthroplasty. J
Mosby; 1986. p. 101–50. Shoulder Elb Surg. 2010;19(2):166–71.
7. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing 25. Budge MD, Lewis GS, Schaefer E, Coquia S,
incidence of shoulder arthroplasty in the United Flemming DJ, Armstrong AD. Comparison of stan-
States. J Bone Joint Surg Am. 2011;93(24):2249–54. dard two-dimensional and three-dimensional cor-
rected glenoid version measurements. J Shoulder Elb 44. Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder
Surg. 2011;20(4):577–83. arthroplasty. Orthop Clin N Am. 2013;44:389–408.
26. Peyron C, Obert L, Runge M, et al. Evaluation of 45. Grammont P, Trouilloud P, Laffay JP, Deries
normal glenoid and humeral landmarks for total gle- X. Concept study and realization of a new total shoul-
nohumeral arthroplasty. ECR 2013 Scientific Exhibit. der prosthesis. Rhumatologie. 1987;39:407–18.
C-0471. PDF available at: 46. Roberts CC, Ekelund AL, Renfree KJ, Liu PT, Chew
27. Takase K, Yamamoto K, Imakiire A, Burkhead WZ Jr. FS. Radiologic assessment of reverse shoulder arthro-
The radiographic study in the relationship of the gle- plasty. Radiographics. 2007;27(1):223–35.
nohumeral joint. J Orthop Res. 2004;22(2):298–305. 47. Harman M, Frankle M, Vasey M, et al. Initial glenoid
28. Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra component fixation in “reverse” total shoulder arthro-
S. The normal glenohumeral relationships. An ana- plasty: a biomechanical evaluation. J Shoulder Elb
tomical study of one hundred and forty shoulders. J Surg. 2005;14:162S–7S.
Bone Joint Surg Am. 1992;74(4):491–500. 48. Virani NA, Cabezas A, Gutierrez S, et al. Reverse
29. Rozing PM, Obermann WR. Osteometry of the gleno- shoulder arthroplasty components and surgical tech-
humeral joint. J Shoulder Elb Surg. 1999;8(5):438–42. niques that restore glenohumeral motion. J Shoulder
30. Kadum B, Sayed-Noor AS, Perisynakis N, Baea S, Elb Surg. 2013;22(2):179–87.
Sjoden GO. Radiologic assessment of glenohumeral 49. Thai DM, Kitagawa Y, Choong PF. Outcome of surgi-
relationship: reliability and reproducibility of lateral cal management of bony metastases to the humerus
humeral offset. Surg Radiol Anat. 2015;37:363–8. and shoulder girdle: a retrospective analysis of 93
31. Fischer CA, Weber MA, Neubecker C, et al. patients. Int Semin Surg Oncol. 2006;3:5.
Ultrasound vs. MRI in the assessment of rotator cuff 50. Bohsali KI, Wirth MA, Rockwood CA Jr.
structure prior to shoulder arthroplasty. J Orthop. Complications of total shoulder arthroplasty. J Bone
2015;12(1):23–30. Joint Surg Am. 2006;88(10):2279–92.
32. Moosikasuwan JB, Miller TT, Burke BJ. Rotator 51. Gregory T, Hansen U, Khanna M, et al. A CT scan
cuff tears: clinical, radiographic, and Us findings. protocol for the detection of radiographic loosening
Radiographs. 2005;25(6):1591–607. of the glenoid component after total shoulder arthro-
33. Sachez-Sotelo J. Total shoulder arthroplasty. Open plasty. Acta Orthop. 2014;85(1):91–6.
Orthop J. 2011;5:106–14. 52. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd.
34. Wiater JM, Fabing MH. Shoulder arthroplasty: pros- Glenoid loosening in total shoulder arthroplasty.
thetic options and indications. J Am Acad Orthop Association with rotator cuff deficiency. J Arthroplast.
Surg. 2009;17(7):415–25. 1988;3(1):39–46.
35. Boileau P, Sinnerton RJ, Chuinard C, Walch 53. Gruen TA, McNeice GM, Amstutz HC. Modes of
G. Arthroplasty of the shoulder. J Bone Joint Surg Br. failure of cemented stem-type femoral components:
2006;88(5):562–75. a radiographic analysis of loosening. Clin Orthop.
36. Churchill RS. Stemless shoulder arthroplasty: current 1979;141:17–27.
status. J Shoulder Elb Surg. 2014;23(9):1409–14. 54. Saltzman MD, Marecek GS, Edwards SL, Kalainov
37. Lazarus MD, Jensen KL, Southworth C, Matsen FA DM. Infection after shoulder surgery. J Am Acad
3rd. The radiographic evaluation of keeled and pegged Orthop Surg. 2011;19(4):208–18.
glenoid component insertion. J Bone Joint Surg Am. 55. Nagels J, Stokdijk M, Rozing PM. Stress shield-
2002;84-A(7):1174–82. ing and bone resorption in shoulder arthroplasty. J
38. Matsen FA III. The ream and run: not for every Shoulder Elb Surg. 2003;12(1):35–9.
patients, every surgeon or every problem. Int Orthop. 56. Merolla G, Di Pietto F, Romano S, et al. Radiographic
2015;39:255–61. analysis of shoulder anatomical arthroplasty. Eur J
39. Copeland SA. Cementless total shoulder replacement. Radiol. 2008;68(1):159–69.
In: Post M, Morrey BF, Hawkins RJ, editors. Surgery 57. Athwal GS, Sperling JW, Rispoli DM, Cofield
of the shoulder. St. Louis: Mosby Year Book; 1990. RH. Periprosthetic humeral fractures during
p. 289–93. shoulder arthroplasty. J Bone Joint Surg Am.
40. Burgess DL, McGrath MS, Bonutti PM, et al. 2009;91(3):594–603.
Shoulder resurfacing. J Bone Joint Surg Am. 58. Wright TW, Cofield RH. Humeral fractures after
2009;91(5):1228–38. shoulder arthroplasty. J Bone Joint Surg Am.
41. Widnall JC, Sheerendra SK, MacFarlane RJ, Waseem 1995;77(9):1340–6.
M. The use of shoulder hemiarthroplasty and humeral 59. Sanchez-Sotelo J, Wright TW, O’Driscoll SW,
head resurfacing: a review of current concepts. Open Cofield RH, Rowland CM. Radiographic assessment
Orthop J. 2013;7(Suppl 3:M7):334–7. of uncemented humeral components in total shoulder
42. Levy O, Copeland SA. Cementless surface replace- arthroplasty. J Arthroplast. 2001;16(2):180–7.
ment arthroplasty (Copeland CSRA) for osteoarthritis 60. Ives EP, Nazarian LN, Parker L, Garrigues GE,
of the shoulder. J Shoulder Elb Surg. 2004;13:266–71. Williams GR. Subscapularis tendon tears: a com-
43. Uribe JW, Botto-van Bemden A. Partial humeral head mon sonographic finding in symptomatic postar-
resurfacing for osteonecrosis. J Shoulder Elb Surg. throplasty shoulders. J Clin Ultrasound. 2013;41(3):
2009;18(5):711–6. 129–33.
61. Alizadehkhaiyat O, Kyriakos A, Singer MS, Frostick 68. Boileau P, Watkinson DJ, Jatzidakis AM, Balq
SP. Outcome of Copeland shoulder resurfacing arthro- F. Grammont reverse prosthesis: design, rationale,
plasty with a 4-year mean follow-up. J Shoulder Elb and biomechanics. J Shoulder Elb Surg. 2005;14(1
Surg. 2013;22:1352–8. suppl S):147S–61.
62. Delaney RA, Freehill MT, Higgins LD, Warner 69. Wahlquist TC, Hunt AF, Braman JP. Acromial
JJP. Durability of partial humeral head resurfacing. J base fractures after reverse total shoulder arthro-
Shoulder Elb Surg. 2014;23:e14–22. plasty: report of five cases. J Shoulder Elb Surg.
63. Sweet SJ, Takar T, Ho L, Tibone JE. Primary par- 2011;10(7):1178–83.
tial humeral head resurfacing: outcomes with the 70. Crosby LA, Hamilton A, Twiss T. Scapula frac-
HemiCAP implant. Am J Sports Med. 2015;43:579. tures after reverse total shoulder arthroplasty: clas-
64. Sirveaux F, Favard L, Oudet D, et al. Grammont sification and treatment. Clin Orthop Relat Res.
inverted total shoulder arthroplasty in the treatment of 2011;469(9):2544–9.
glenohumeral osteoarthritis with massive rupture of 71. Walch G, Mottier F, Wall B, et al. Acromial insuffi-
the cuff. Results of a multicenter study of 80 shoul- ciency in reverse shoulder arthroplasties. J Shoulder
ders. J Bone Joint Surg Br. 2004;86(3):388–95. Elb Surg. 2009;18(3):495–502.
65. Boileau P, Watkinson D, Hatzidakis AM, et al. The 72. Florschutz AV, Lane PD, Crosby LA. Infection after
Grammont reverse shoulder prosthesis: results in cuff primary anatomic versus primary reverse total shoul-
tear arthritis, fracture sequelae, and revision arthro- der arthroplasty. J Shoulder Elb Surg. 2015; Epub
plasty. J Shoulder Elb Surg. 2006;15(5):527–40. ahead of print.
66. Scarlat MM. Complications with reverse total shoul- 73. Ladermann A, Lubbeke A, Melis B, et al. Prevalence
der arthroplasty and recent evolutions. Int Orthop. of neurologic lesions after total shoulder arthroplasty.
2013;37:843–51. J Bone Joint Surg Am. 2011;93:1288–93.
67. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, 74. Kaback LA, Green A, Blaine TA. Glenohumeral
Mole D. Grammont inverted total shoulder arthro- arthritis and total shoulder replacement. Med Health
plasty in the treatment of glenohumeral osteoarthritis R I. 2012;95(4):120–4.
with massive rupture of the cuff: results of a multi- 75. Pritchett JW. Long-term results and patient satisfac-
centre study of 80 shoulders. J Bone Joint Surg Br. tion after shoulder resurfacing. J Shoulder Elb Surg.
2004;86(3):388–95. 2011;20(5):771–7.
Part V
Miscellaneous
Imaging Diagnosis of Tumors
and Tumorlike Conditions 12
of the Shoulder
Eric A. Walker, Matthew J. Minn,

and Mark D. Murphey
12.1 Anatomy the biopsy track is no problem if an amputation is

performed but may cause significant difficulties
Anatomic compartments are defined by natural in the case of limb-salvage procedures if inappro-
barriers that also limit the spread of a tumor [1]. priately placed. The radiologist must have a clear
Local staging of a malignancy depends on which understanding of the relevant compartmental
anatomic compartments are involved and this anatomy for staging a tumor and avoid unneces-
determination is best accomplished with cross- sarily contaminating uninvolved anatomic com-
sectional imaging, preferably magnetic reso- partments during biopsy. When biopsying a bone
nance imaging (MRI). Although several staging or soft-tissue tumor it is advisable to discuss your
systems exist, they are all based on the histologic biopsy approach with the surgeon performing the
grade of the tumor, the local extent of the lesion, resection. Failure to do so may result in the
and the presence of metastases. Regarding local biopsy tract within an anatomic region needed for
extent, lesions confined to one specific compart- limb-sparing surgery. Different compartments
ment are considered intracompartmental. specific to the upper extremity and shoulder
Extracompartmental lesions have spread beyond include the muscles and fascia covering the dor-
the compartment of origin [1]. Another consider- sal scapula (infraspinatus, teres minor, and rhom-
ation requiring knowledge of compartmental boid muscles), the supraspinatus and deltoid
anatomy is planning a biopsy path. Resection of compartments, and the anterior and posterior
compartments of the upper arm (Fig. 12.1) [1].
The anterior compartment contains the biceps,
The authors have nothing to disclose.
The opinions or assertions contained herein are the private brachialis, coracobrachialis, and brachioradialis
views of the authors and are not to be construed as official muscles. The posterior compartment is primarily
nor as reflecting the views of the departments of the army, the triceps musculature [2]. More general com-
navy, or defense.
E. A. Walker (*)
Department of Radiology, Milton S. Hershey Medical M. D. Murphey
Center, Hershey, PA, USA American Institute for Radiologic Pathology,
Silver Spring, MD, USA
Departments of Radiology and Nuclear Medicine,
Uniformed Services University Departments of Radiology and Nuclear Medicine,
of the Health Sciences, Bethesda, MD, USA Uniformed Services University
e-mail: ewalker@hmc.psu.edu of the Health Sciences, Bethesda, MD, USA
M. J. Minn Walter Reed Army Medical Center,
American Institute for Radiologic Pathology, Washington, DC, USA
Silver Spring, MD, USA e-mail: mmurphey@acr.org

270 E. A. Walker et al.
Anterior compartment Anterior compartment
Posterior compartment Posterior compartment
Fig. 12.1 The posterior compartment contains the medial containing the median nerve, basilic vein, and brachial
(MHT), lateral (LaHT), and long (LHT) heads of the tri- artery. Arrowhead is to the neurovascular bundle contain-
ceps brachii. The anterior compartment contains the bra- ing the radial nerve and radial collateral artery and vein.
chialis muscle (B) and long (LHB) and short (SHB) heads Curved arrow is to the ulnar nerve. Cephalic vein anno-
of the biceps brachii. Arrow is to the neurovascular bundle tated with an asterisk
partments are the skin and subcutaneous fat, the a lesion and formulating a differential diagnosis,
muscle, the nerves and vessels, the parosseous it is important to consider the age and sex of the
space, the bones, and the joints [2]. When describ- patient, the lesion location, the lesion margin, the
ing a lesion, it is important to note which com- formation of mineralized matrix, and the pres-
partments are involved. When performing a ence of periosteal reaction (Fig. 12.2a, b). The
biopsy of the shoulder through the deltoid mus- lesion location includes which bone is involved,
cle, the path should be through the anterior del- the longitudinal location (epiphyseal, metaphy-
toid. The axillary nerve innervates the deltoid seal, or diaphyseal), and the axial location (cen-
muscle from posterior to anterior. If a needle tral, eccentric, cortical, and juxtacortical/
track is chosen in the posterior two-thirds of the parosteal). Lesions often present within a charac-
muscle, the remaining anterior portion of the del- teristic location in the skeleton. The lesion m
argin
toid may become denervated and functionless or zone of transition suggests the aggressiveness
after resection of the posterior muscle [2] and or growth rate of the lesion. A geographic 1A
may require amputation. lesion is a single well-defined lytic lesion with a
sclerotic border and is the least aggressive pat-
tern. The geographic 1B lesion is well defined
12.2 n Approach to Bone
A without a sclerotic border. The growth is likely
Tumors slow to intermediate. The geographic 1C is an ill-
defined single lytic lesion with intermediate
The authors value the radiograph as the first and growth. Moth-eaten and permeative patterns con-
most important diagnostic tool in evaluating a sist of multiple small lytic foci and suggest a
bone tumor and considering a differential diag- highly aggressive lesion. Mineralized matrix can
nosis. Cross-sectional imaging is typically subse- be characterized as chondroid (ring and arc, hon-
quently performed for staging. When considering eycomb, or flocculent), osteoid (ivory, solid,
12 Imaging Diagnosis of Tumors and Tumorlike Conditions of the Shoulder 271
a b
Fig. 12.2 Figure (a) represents the margins and perios- (b) demonstrates the patterns of more aggressive margins
teal reactions usually associated with nonaggressive and periosteal reactions. A geographic 1C lesion (white
lesions. Margins demonstrated are the geographic 1A arrow) is noted with ill-defined lesion borders. The very
lesion (white arrow), which is well defined with a scle- aggressive moth-eaten (white arrowhead) and permeative
rotic border and the geographic 1B lesion (white arrow- (white curved arrow) patterns are also shown. Aggressive
head) that is well defined without a sclerotic border. The periosteal reactions include the sunburst (black solid
black arrow indicates a solid, slow-growing periosteal arrow), hair-on-end (black hollow arrow), onionskin
reaction and the black arrowhead reveals an area of sau- (black arrowhead), and Codman triangle (black curved
cerization with a buttressing periosteal reaction. Figure arrow)
lumpy, or cloudlike), and ground glass (usually 12.3 Benign Bone Tumors
indicating a diagnosis of fibrous dysplasia).
Nonaggressive periosteal reactions include solid, 12.3.1 B
enign Osteoid Lesion:
buttressing, expansile, and septated. Aggressive Osteoid Osteoma
periosteal reactions include the Codman triangle,
laminated/onion skin, hair on end, and sunburst Osteoid osteoma is a benign lesion composed of
presentations. Several articles contain a osteoid and woven bone, both of which can be
more thorough discussion of bone tumor seen as interconnected trabeculae, sheets, or iso-
characteristics [3–7]. lated islands with no malignant potential [8]. It is
a relatively common skeletal lesion that accounts high T2-weighted signal. The findings of a round
for nearly 12% of benign skeletal neoplasms [9]. or oval lesion less than 1.5–2 cm in diameter
Osteoid osteoma presents in young patients, with within or adjacent to thickened cortex and marked
approximately 50% presenting between the ages marrow edema and synovitis of a nearby joint
of 10 and 20 years. The lesion is uncommon in may suggest the diagnosis.
patients less than 5 years or greater than 40 years Medical treatment may consist of aspirin or
of age. There is a male predilection with a male- other NSAIDs. Computed tomography (CT)-
to-female ratio of approximately 1.6:1. The pre- guided percutaneous radiofrequency ablation is
senting symptom is pain, varying in duration frequently performed at our institutions with an
from weeks to years. Pain is frequently worse at 84–94% cure rate [12].
night, may awaken the patient from sleep, and is A reasonable differential diagnosis for an area
often relieved by aspirin or nonsteroidal anti- of mature periosteal thickening includes osteoid
inflammatory drugs (NSAIDS). Intra-articular osteoma, subacute osteomyelitis (Brodie’s
lesions often present with nonspecific joint pain. abscess), Langerhans cell histiocytosis, and stress
Swelling may be associated with superficial fracture.
lesions such as those in the fingers and toes [8].
Osteoid osteoma may occur in any bone, but
there is a predilection for the lower extremity, 12.3.2 B
enign Chondroid Lesions
with more than 50% occurring in the femur and of Bone (Chondroblastoma,
tibia. The large majority of lesions arise in the Osteochondroma, Periosteal
cortex of long bones, typically diaphyseal or Chondroma,
metadiaphyseal. Only 10–15% of cases of oste- and Enchondroma)
oid osteoma occur in the shoulder favoring the
proximal end of the humerus or glenoid [10]. 12.3.2.1 Chondroblastoma
On radiograph, the lesion is characterized by a The chondroblastoma (also called Codman
nidus of osteoid tissue less than 1.5–2 cm in tumor) (Fig. 12.3) is a benign, cartilage-
diameter surrounded by a larger area of dense producing tumor usually arising in the epiphyses
fusiform reactive osteosclerosis (solid periosteal of skeletally immature individuals [13]. The
reaction). The nidus may be located cortically lesion represents approximately 9% of benign
(70–75%), medullary (25–30%), or subperiosteal bone tumors.
and may be radiolucent or contain a variable The lesion presents in children and young
amount of mineralization [8]. The periosteal adults with 90% between age 5 and 25 years.
reaction may obscure the nidus on plain radio- There is a male predilection of 2:1. The clinical
graphs. An intra-articular location of the nidus presentation of chondroblastoma is typically pain
prevents significant periosteal reaction due to dif- (98%), local tenderness (90%), stiffness (74%),
ferences in the intracapsular periosteum. swelling (40%), and joint effusion (4%) [14]. The
Computed tomography (CT) is often the best lesion usually presents in the epiphyses of the
modality to identify the round or oval nidus of long bones, most often the distal femur (20%),
decreased attenuation within the surrounding proximal humerus (17%), and proximal tibia
reactive bone. Bone scintigraphy may demon- (17%) [15].
strate the double-density sign in which there is a The lesion is often eccentric on radiograph and
small area of focal intense radionuclide activity is usually well defined with a thin sclerotic border
corresponding to the nidus, superimposed on a (geographic 1A–1B). In 25–50% of lesions, stip-
second larger area of lesser tracer accumulation pled calcifications are present on radiographs
related to the surrounding periosteal reaction [8]. [11]. The tumor is classically located adjacent to
The nidus of osteoid osteoma has been described the growth plate with almost 50% of the cases
with variable signal characteristics on MRI [11] limited to the epiphysis and many extending for a
but most often with low-to-intermediate T1- and variable distance into the metaphysis [14].
a b
Fig. 12.3 Chondroblastoma: 17-year-old male presents with fat saturation shows metaphyseal to epiphyseal
with right-shoulder pain. Radiograph (a) demonstrates a lesion (arrowhead) extension with low signal and signifi-
geographic 1B lesion (arrow) involving the medial proxi- cant surrounding edema. Imaging characteristics favoring
mal humeral metaphysis adjacent to the physeal scar. the diagnosis of chondroblastoma include epiphyseal
Axial CT (b) reveals subtle calcifications (curved arrow) extension, lesion mineralization, low T2-weighted
within the lesion. T2-weighted (TR4916, TE72) MR (c) signal, and edema surrounding the lesion
Periosteal reaction may be present in 30–62% of been described in 50% of cases in one study [16]
cases and is also in the metadiaphysis. CT may be likely secondary to an inflammatory response.
useful for visualizing features such as faint matrix Bone scintigraphy demonstrates uptake on vascu-
(90–95% with matrix on CT) not seen on radio- lar and delayed phases. On MRI, chondroblas-
graph, an extraosseous extension, or a sclerotic toma typically demonstrates intermediate
margin. A solid or layered periosteal reaction has T1-weighted signal intensity and in the majority
of cases either complete or partial T2W hypoin- in an excellent outcome [14]. Radiofrequency
tensity (90–95%), which may be related histologi- ablation has recently been advocated for small
cally to abundant immature chondroid matrix, lesions.
hypercellularity of chondroblasts, calcifications, The benign bone tumors most commonly
and hemosiderin deposition [14]. The low lesion resulting in bone marrow edema include osteoid
signal on fluid-sensitive sequences is a distin- osteoma, osteoblastoma, chondroblastoma, and
guishing feature as it is uncommon in bone Langerhans cell histiocytosis. Bone metastases
tumors. Postcontrast sequences reveal either lobu- and primary malignant bone tumors such as
lar or peripheral/septal enhancement. The major- osteosarcoma, Ewing’s sarcoma, and chondro-
ity of cases (>90%) show marked perilesional sarcoma may also be surrounded by bone marrow
bone marrow edema (another distinguishing char- edema, particularly if associated with a patho-
acteristic). Periostitis, soft-tissue edema, and joint logic fracture [17].
effusion with synovitis are also commonly seen
[14]. Fluid levels suggest an aneurysmal bone 12.3.2.2 Osteochondroma
cyst (ABC) component in 21–77% of lesions. The osteochondroma (Fig. 12.4) is a benign
Chondroblastoma is typically treated with an lesion composed of a cartilage-capped osseous
intralesional curettage and packing of the defect projection on the bone surface. The lesion con-
with bone graft or cement, which usually results tains a marrow cavity demonstrating cortical
a b
Fig. 12.4 Osteochondroma: 13-year-old male with upper is noted in the cartilage cap on the radiograph. The MR
arm pain. Radiograph (a) and axial T2-weighted (TR3250, best demonstrates the cartilage cap (arrowhead) thickness.
TE70) image (b) with fat saturation demonstrate an exo- This cartilage cap is less than the 2 cm thickness sugges-
phytic mass (sessile osteochondroma) with cortical and tive of malignant transformation
medullary continuity (arrows). Typical chondroid matrix
and medullary continuity with the underlying enchondral bone formation. There is generally
bone. Osteochondroma is the most common more prominent radionuclide uptake in the
bone tumor. It constitutes 20–50% of benign osteochondromas of younger patients [18].
bone tumors and 10–15% of all bone tumors Cross-sectional imaging may be required to
[18]. Osteochondromas may be solitary lesions demonstrate cortical and medullary continuity in
or multiple, the latter being associated with the flat bones or areas of complex anatomy (pelvis,
autosomal dominant syndrome hereditary mul- spine, scapula). CT is very useful in depicting
tiple exostoses (HME). Osteochondromas are the pathognomonic cortical and medullary conti-
discovered before the age of 20 years in 75–80% nuity of the lesion and parent bone. Measurement
of cases. Solitary osteochondroma has a male of hyaline cartilage cap thickness with CT has
predilection, from 1.6–3.4 to 1 [18]. The most met with variable success in the literature, and
common symptom related to the osteochon- cap mineralization increases the accuracy with
droma is a non-tender, painless deformity CT. The unmineralized cartilage cap is usually
related to the slowly enlarging exophytic mass. lower in attenuation than skeletal muscle, sec-
Additional complications that may cause symp- ondary to its high water content [18]. Ultrasound
toms include osseous deformity and mechani- (US) may be more accurate than CT and similar
cal impingement, fracture, vascular compromise to MR imaging in the evaluation of cartilage cap
and pseudoaneurysm, neurologic sequelae, thickness if the lesion is accessible to US assess-
adventitial bursa formation, and malignant ment [18]. The cartilage cap on US appears as a
transformation. Malignant transformation is hypoechoic layer. Areas of mineralization in the
observed in approximately 1% of solitary cartilage cap and the underlying osseous compo-
osteochondromas and in 3–5% of patients with nent show posterior acoustic shadowing. MR
HME [18]. The long bones of the lower extrem- imaging also demonstrates cortical and medul-
ity are most frequently affected (50% of cases), lary continuity between the osteochondroma and
often about the knee (40% of cases). parent bone. MR imaging (in the authors’ opin-
Osteochondromas about the shoulder include ion) is the best radiologic modality for visualiz-
humeral involvement (10–20% of cases) and ing the effect of the lesion on surrounding
scapula (4% of cases) [18]. structures and evaluating the hyaline cartilage
The radiographic appearance of solitary osteo- cap thickness. The cartilage cap demonstrates
chondroma is frequently pathognomonic, partic- intermediate to low signal intensity on
ularly in long bones. The lesion is composed of T1-weighted images and very high signal inten-
cortical and medullary bone arising from and sity on T2-weighted or fluid-sensitive sequences
continuous with the underlying bone. [18]. Intravenous administration of gadolinium-
Osteochondromas may be sessile (broad and based contrast reveals typical chondroid periph-
flat) or pedunculated (narrow with a bulbous eral and septal enhancement (similar to
tip). Pedunculated lesions usually point away enchondroma or low-grade chondrosarcoma) in
from the nearest joint. Identifying the character- the cartilage cap. Cartilage cap thickness of 2 cm
istic cortical and medullary continuity between or greater in skeletally mature patients is strongly
lesion and parent bone is key for diagnosis. The indicative of malignant transformation to sec-
radiographic appearance of the hyaline cartilage ondary chondrosarcoma [19].
cap is quite variable on radiographs. The chon- The treatment of osteochondroma is follow-
droid nature of this region is often suggested by ups and only supportive care with small asymp-
the identification of arcs and rings or flocculent tomatic or minimally symptomatic lesions. Larger
calcification. The thickness of the cartilage cap symptomatic lesions may be surgically resected at
is not well evaluated with radiography unless their base. Pedunculated lesions are more easily
there is extensive chondroid mineralization. resected. The overall recurrence rate after removal
Bone scintigraphy of osteochondroma is vari- has been estimated at 2%. It is important to
able and is directly correlated with the degree of entirely resect the overlying perichondrium
because inadequate excision of this tissue signifi- ture hyaline cartilage with small chondrocytes
cantly increases the risk of lesion recurrence [18]. interspersed throughout the cartilaginous tissue.
Areas of calcification and mucoid degeneration
12.3.2.3 Periosteal Chondroma are common [20]. Periosteal chondromas repre-
Periosteal chondroma (Fig. 12.5) is a benign hya- sent less than 2% of bone neoplasms. The lesion
line cartilage neoplasm arising on the surface of a is more common in males with a mean age of
bone beneath the periosteum. Synonyms include 27 years at presentation [20]. These lesions have a
juxtacortical chondroma and parosteal chon- predilection for the proximal metaphyses or meta-
droma [13]. Histology reveals lobules of imma- diaphyses of the long tubular bones, most com-
a b
Fig. 12.5 Periosteal chondroma: 19-year-old male with Axial CT (b) demonstrates lesion attenuation less than
anterior lateral right-shoulder lump for 11 months. adjacent skeletal muscle (arrow). Axial T1-weighted
Radiograph (a) reveals a juxtacortical lesion. There is mild image (c) with fat saturation after gadolinium contrast
saucerization (arrow) and partial cortical shell. Cortical administration demonstrates the classic peripheral (arrow-
buttressing is present at the lesion edges (arrowhead). heads) and septal chondroid enhancement pattern (arrow)
monly the proximal humerus (50%) followed by foci at areas of mineralized matrix. Postcontrast
the femur and tibia. Short tubular bones of the images reveal peripheral and septal enhancement
hands and feet are the next most frequent loca- similar to other chondroid lesions.
tions [20]. Local swelling, which may be associ- Distinguishing between periosteal chondroma
ated with mild pain, is the most common clinical and low-grade periosteal chondrosarcoma may
presentation. Lesions are frequently traumatized be difficult. The best distinguishing characteristic
due to their location on the surface of bone [20]. is lesion size. The mean size of a periosteal chon-
The classic appearance of periosteal chondrosarcoma (range 3–14 cm, mean 5.3 cm) is
droma on radiograph is a small (1–3 cm) area of larger than that of periosteal chondroma (range
scalloping (saucerization) of the cortex with 1–6.5 cm, mean 2.2 cm). Additional imaging
adjacent soft-tissue mass. There is usually a well- findings favoring chondrosarcoma are intramed-
defined sclerotic margin between the tumor and ullary extension, intramedullary edema, soft-
underlying bone. The outer margin of the lesion tissue edema, and irregular soft-tissue margins on
may be seen as a thin cortical shell or may be MR imaging [21].
absent on radiographs. Soft-tissue mass with Treatment of these lesions is surgical, with a
mild-to-moderate amount of cartilaginous miner- wide excision performed for periosteal chondro-
alized matrix is seen in approximately 50% of sarcoma and a local excision for periosteal
cases [20]. Periosteal reaction may present as chondroma [21].
cortical buttressing at the lesion margins [11]. CT
better demonstrates the cortical saucerization and 12.3.2.4 Enchondroma
chondroid matrix. The subperiosteal soft-tissue Enchondromas (Fig. 12.6) are benign hyaline
component shows lower attenuation than skeletal cartilage neoplasms of medullary bone that are
muscle. MR imaging demonstrates isointense or hypocellular and hypovascular with abundant
low T1 signal and increased T2 signal, with dark hyaline cartilage matrix [13]. Solitary lesions
a b
Fig. 12.6 Enchondroma: 58-year-old female with frozen ing. (b) Coronal T1-weighted (TR505, TE16) sequence
shoulder and failure of 2 months of physical therapy. reveals a central lesion with signal similar to skeletal mus-
Grashey view radiograph (a) demonstrates ring-and-arc cle. The lesion shows lobular growth with fat present
calcifications with central flocculent matrix (arrow). between lobules at the proximal margin (arrowhead)
There is no deep endosteal scalloping or cortical remodel- “prominent fat trapping”
predominate; however they may be polyostotic. lage may be separated by thin septae that are low
Multiple enchondromas are a feature of Ollier in signal. Foci of low signal on T1- and
disease and Maffucci syndrome. Enchondromas T2-weighted images represent mineralized
are quite common and are the second most com- matrix [23]. MR imaging most reliably deter-
mon benign tumor of bone, representing mines the absence of a soft-tissue component.
10–25% of all benign bone tumors [22]. Because Following gadolinium administration, a periph-
enchondromas usually do not undergo biopsy, eral and/or septal enhancement pattern is most
the true prevalence is likely underestimated. common. Enchondromas tend to demonstrate
The lesion may occur at any age but mostly homogeneous and mild-to-moderate uptake of
present between the second and fourth decades radiotracer on whole-body bone scintigraphy in
of life. There is no significant sex predilection. comparison to the anterior iliac spines [23].
Enchondroma is frequently asymptomatic and is Many studies also report positive results regard-
discovered incidentally or after a pathologic ing the ability of fluorodeoxyglucose-positron-
fracture through phalangeal lesions. The short emission tomography (FDG-PET) to differentiate
tubular bones of the hands and feet (40–65%) between benign and higher grade malignant car-
are the most common locations followed by the tilaginous lesions [22].
femur, humerus, and tibia [11]. The lesion Features that favor the diagnosis of enchon-
occurs in the proximal end of the humerus in droma over chondrosarcoma include absence
10–15% of cases [10]. of pain, patient age younger than the fourth
Radiographs of tubular long bone lesions usu- decade of life, lesion size less than 4 cm,
ally reveal the typical ring and arc chondroid absence of deep endosteal scalloping (typically
matrix mineralization (95%). Lesions usually much <2/3 of the normal cortical thickness),
present centrally or eccentrically in the metaphy- absence of cortical periosteal reaction/thicken-
sis and diaphysis. Mild (typically much <2/3 of ing/remodeling, absence of soft-tissue exten-
the normal cortical thickness) scalloping of the sion, a lack of marrow edema surrounding the
cortex may be present. The lesion margin is usu- lesion, prominent fat trapping at the lesion
ally well defined to poorly defined (geographic margin on T1 sequences, uptake of radiotracer
1B to 1C). Lesion extent may be difficult to char- usually less than the anterior iliac crest on
acterize accurately on radiographs particularly if whole-body bone scintigraphy, and lack of
mineralization is not prominent. Periosteal reac- hypermetabolic foci on FDG-PET. Involvement
tion, cortical destruction, soft-tissue extension, of the axial skeleton is very uncommon for a
and extensive cortical remodeling are unex- solitary enchondroma [22].
pected findings in long-bone enchondroma [23]. Surgical treatment is frequently unnecessary.
CT is more sensitive in detecting the presence Curettage and packing with bone graft material
and character of subtle chondroid matrix miner- are the typical methods of surgical excision when
alization and more accurately quantifies the required. Recurrence is rare.
extent of endosteal scalloping than radiography.
Enchondromas present as marrow replacement
that is low to intermediate in signal on 12.3.3 Non-ossifying Fibroma
T1-weighted images. Foci of high T1 signal may
be noted at the periphery of an enchondroma Non-ossifying fibroma (NOF) (Fig. 12.7) is a
representing surrounded yellow marrow “trapped benign fibroblastic proliferative lesion containing
fat.” The lobular growth of the enchondroma is osteoclast-type giant cells. The name fibrous cor-
best revealed on T2-weighted or other fluid- tical defect is used when the lesion is smaller and
sensitive sequences. The lesion is high (similar confined to the bone cortex and the patient is
to fluid) signal on T2-weighted MR images sec- younger. NOF is the term for larger lesions in
ondary to the high water content (75–80%) of older patients that extend into the medullary cav-
hyaline cartilage and individual lobules of carti- ity [13]. Some authors prefer the nomenclature
margin is usually (66%) sclerotic (geographic

1A). During involution they can undergo osteo-
sclerosis [11, 13]. No periosteal reaction is pres-
ent in the absence of pathologic fracture. CT may
better demonstrate cortical thinning and medul-
lary involvement. Hounsfield units within the
lesion are higher than normal bone marrow.
Scintigraphy reveals minimal to mild increase in
radionuclide uptake [11]. With MRI, the lesion
shows low signal intensity on T1 compared with
that of skeletal muscle. T2-weighted signal is
more commonly low, but may be high.
T2-weighted signal may decrease as the lesion
matures. Enhancement may be diffuse or mar-
ginal and septal [24].
Most NOFs heal spontaneously and require no
surgical intervention. Treatment is reserved for
lesions with atypical radiographs (requiring biopsy)
or for symptomatic or larger lesions that require
Fig. 12.7 Fibroxanthoma: Lesion incidentally noted in a treatment to prevent pathologic fracture [25].
40-year-old male with bilateral shoulder pain. Radiograph A differential for “bubbly”-appearing lesions
reveals an eccentric lesion (arrowhead) involving the of bone includes fibroxanthoma, chondroid
metaphyseal outer medullary space with a sclerotic (geo-
lesions, giant-cell tumor, chondromyxoid fibroma,
graphic 1A) border. There is no periosteal reaction
adamantinoma, osteofibrous dysplasia, and des-
moplastic fibroma.
fibroxanthoma to refer to both of these lesions.
Benign fibrous histiocytoma has the same histo-
logic features but involves the non-metaphyseal 12.3.4 Fibrous Dysplasia
region of long bones or the pelvis in older patients
[13]. The incidence of NOF is unknown but is Fibrous dysplasia (FD) is a benign, medullary,
stated as the most common fibrous lesion of bone fibro-osseous lesion, which may involve one
by some authors [11]. It has been estimated that bone (monostotic 70–80%) or multiple bones
30–40% of children have one or more occult (polyostotic 20–30%). The lesion contains
lesions [13]. There is a 2:1 male predilection and fibrous and osseous tissue present in varying pro-
most lesions are identified in the first and second portions [13]. Syndromes associated with the
decades of life [11]. Multiple NOF lesions may polyostotic form include McCune-Albright syn-
be present in neurofibromatosis type 1 and Jaffe- drome and Mazabraud syndrome. Fibrous dys-
Campanacci syndrome. NOF lesions are usually plasia most commonly presents in the second and
asymptomatic and discovered incidentally unless third decades of life. There is an equal distribu-
a pathologic fracture is present. Fibroxanthoma is tion between the sexes. The majority of lesions
seen most frequently in the distal femur (38%), are asymptomatic and incidentally found at radi-
proximal tibia, and distal tibia. Less common ography. Fibrous dysplasia may present with a
sites are the humerus (5%) and fibula [11]. pathologic fracture, particularly in the femoral
Radiographs are often diagnostic. NOF lesions neck [26]. The most common locations affected
are eccentric elliptical, lucent lesions involving include the femur (35%), tibia (20%), and ribs
the metaphyseal cortex and much less commonly (10%). The humerus and skull are also common.
extending into the medullary space. Lesions are A common presentation of fibrous dysplasia is
uniloculated or multiloculated (bubbly) and the pain related to pathologic fracture. The risk of
developing pathologic fracture is accentuated

when there is a coexisting aneurysmal bone cyst,
further weakening the diseased bone. Malignant
degeneration complicates less than 1% of all
cases, presenting clinically as pain, rapid growth,
and swelling [27].
The radiographic appearance depends on the
proportion of osseous to fibrous tissue present.
Fibrous dysplasia lesions are intramedullary,
expansile, and well defined. Diffuse endosteal
scalloping may be present. Lesions show varying
degrees of hazy density with a “ground-glass”
quality. Occasionally lesions may appear almost
completely radiolucent or sclerotic. Greater ossi-
fication leads to denser and more sclerotic
lesions. Lesions may demonstrate a thick periph-
eral band of reactive bone or “rind” sign. FD
often reveals a nonspecific marked increased
uptake of radiotracer on bone scans. Lesion SUV
may range from 3 to 19 on FDG-PET. CT and
MR cross-sectional imaging are useful for evalu-
ating for soft-tissue components and the extent of
a lesion. The MR characteristics are variable, Fig. 12.8 Unicameral bone cyst: 5-year-old male with
pathologic fracture and occasional aching pain.
with lesions typically showing intermediate to
Radiograph demonstrates a well-defined, geographic 1A
low signal on T1-weighted images and interme- lesion with mild cortical buckling from prior pathologic
diate to high signal on T2-weighted images. The fracture (arrow). The lesion is located in the central,
sclerotic rim (rind sign) presents as a band of low metaphyseal region of the humerus adjacent to the physis
and demonstrates a thin sclerotic rim
signal on T1- and T2-weighted sequences.
Heterogeneous enhancement after the adminis-
tration of gadolinium is typical [27]. pathogenesis is believed to be caused by a
Differential diagnosis for lesions involving venous circulation disorder within the cancel-
multiple bones (polyostotic processes) includes lous bone, in which a blockage of venous flow
the benign entities of Langerhans cell histiocyto- leads to increasing pressure and bone resorption
sis, enchondromatosis, fibrous dysplasia, heredi- [30]. UBC is an uncommon lesion, representing
tary multiple exostoses, osteomyelitis, Paget approximately 3% of all primary bone tumors
disease, and angiomatous lesions. Metastases, [28, 31]. These lesions typically occur in chil-
multiple myeloma, lymphoma, and hemangioen- dren and adolescents and traditionally present in
dothelioma are polyostotic malignant entities. the first two decades of life. There is a 2.5:1
male predominance and the lesions are usually
solitary without clinical impact [28, 31]. Many
12.3.5 Unicameral Bone Cysts lesions are asymptomatic and discovered inci-
dentally when imaging adjacent body parts for
Unicameral bone cysts (UBC) or simple bone various clinical reasons. When symptomatic, a
cysts (Fig. 12.8) are benign fluid-filled cystic spontaneous fracture of the superior humeral
lesions lined by mesothelial cells, which may be neck and femoral neck is the most common
unilocular or multilocular with septations [28, finding. Pathologic fracture occurs in up to 66%
29]. UBCs are thought to be a dysplastic or of cases [11]. The UBC originates in the
reactive lesion rather than a true neoplasm. The metaphyseal region of long bones abutting the
epiphyseal plate; however with patient growth it pain. Combinations of surgical and nonsurgical
may migrate toward the diaphysis (latent UBC). techniques ranging among radiological surveil-
Based on the distance between the cyst and the lance, intracyst injection (steroids, bone marrow
growth plate, a UBC is classified as active when or bone substitutes), cyst wall fenestration with
the distance is less than 5 mm and latent when aspiration, intracyst curettage, and internal fixa-
greater than 5 mm from the growth plate [32]. tion have been described to treat UBC without a
These lesions primarily involve the proximal clear treatment consensus. In the setting of frac-
humerus (50–60%), followed by the proximal ture, closed treatment (cast or sling immobiliza-
femur (30%). tion) is the primary treatment, which often is
On radiographs, UBCs are typically located in enough to cause resolution and healing of the
the central, metaphyseal region of long bones UBC [34].
adjacent to the physis and are well-defined, geo-
graphic 1A lesions with a thin sclerotic rim.
These may cause mild expansile remodeling of 12.3.6 Aneurysmal Bone Cyst
bone with diffuse thinning of the surrounding
cortex. The majority of cases demonstrate no Aneurysmal bone cyst (ABC) (Fig. 12.9) is a
periosteal reaction, soft-tissue component, or benign, osteolytic, usually expansile lesion con-
matrix mineralization [11]. In instances of frac- sisting of multiple blood-filled spaces. ABC
ture, an osseous fragment may migrate to the may arise as a de novo lesion (primary or classi-
dependent portions of the intracystic fluid. This cal type) or may develop secondarily to a benign
“fallen fragment sign” is considered pathogno- bone lesion such as giant-cell tumor (GCT),
monic for UBC, although it is only seen in about osteoblastoma, chondroblastoma, chondromyx-
5% of cases [33]. Bone scintigraphy may be nor- oid fibroma, FD, or NOF [29]. They may also be
mal or demonstrate increased peripheral uptake secondary to malignant bone lesions (osteosar-
with central decreased activity. On FDG-PET coma, fibrosarcoma, chondrosarcoma) as well
imaging the lesions are without hypermetabolic [11]. ABC is approximately 1% of biopsied pri-
activity [11, 30]. On cross-sectional imaging, mary osseous neoplasms and there may be a
UBCs show a thin-walled lesion with the absence slight female predominance. ABC is noted at all
of matrix mineralization. CT better characterizes ages, but most (75–90% of cases) occur before
the sclerotic margins and expansile remodeling the age of 20. The most common symptoms of
and may be helpful if the lesion is atypical or lesions in the long bones are pain and local
located in the pelvis. There may be prominent swelling. Aneurysmal bone cysts can involve
osseous ridges or trabeculae within the lesion, any part of the skeleton, but are most common
but most UBCs are made of one contiguous cyst. to affect the long bones (67%), spine (15%), and
The attenuation coefficient values (Hounsfield pelvis (9%). The metaphysis is most often
units) can range from 15HU to 20HU within the involved (80–90%), and the bones most fre-
cysts. MR confirms the cystic components within quently involved are the distal femur, tibia,
the lesion with signal characteristics following humerus, and fibula. ABC and UBC affect a
fluid. An uncomplicated UBC has uniform high similar population and location (proximal
signal on T2-weighted sequences and is low to humerus, proximal femur) and the aspiration of
intermediate signal on T1-weighted images. fluid is nonspecific.
Postcontrast images demonstrate a thin rim of At radiograph, ABC presents as a multicys-
peripheral enhancement without nodular compo- tic, eccentric, osteolytic, expansile, and some-
nents. Fractured UBCs may contain hemorrhage, times trabeculated lesion containing fine-walled
fluid levels, and nodular enhancement [30]. cystic cavities. Lesions with marked expansile
UBC is a self-limited benign bone lesion. The bone remodeling may have a “blowout” appear-
purpose of treatment is to prevent pathologic ance. The lesion has a narrow zone of transition
fracture and to manage symptoms, especially and sometimes a sclerotic margin (geographic
a b
Fig. 12.9 Aneurysmal bone cyst: 22-year-old Latino osteolytic lesion (arrow) with a “blownout” appearance.
male with chronic shoulder pain after a fall from horse 6 (b) Axial STIR sequence (TR5565, TE30) demonstrates
months prior. Radiograph (a) reveals a large multicystic multiple cystic spaces with fluid levels (arrowheads)
1A or 1B) at the medullary margin but more 12.3.7 Giant-Cell Tumor

aggressive appearance at the cortical margin,
which often cannot be seen on radiographs. The Giant-cell tumor (GCT) of bone (Fig. 12.10) is a
cortical or periosteal shell surrounding ABC and benign, locally aggressive lesion composed of
lack of soft-tissue extension are better delin- sheets of neoplastic ovoid mononuclear cells
eated with CT. The attenuation coefficient val- interspersed with uniformly distributed large,
ues (Hounsfield units) can range from 20HU to osteoclast-like giant cells [13]. These lesions
75HU [11]. Fluid levels are often appreciated on account for approximately 5–10% of primary
CT in up to 30% of cases secondary to sedimen- bone tumors. GCT of bone has the potential for
tation of red blood cells [29]. Bone scintigraphy more aggressive behavior “malignant giant-cell
may show increased radionuclide uptake in a tumor” with metastatic pulmonary spread in less
ringlike pattern around the periphery of the than 2% of cases [35, 36]. GCT typically devel-
lesion (65%). The typical MRI appearance is an ops in younger adults aged 20–50 years and
expansile lesion either lobular or with septa. there is a 2:1 female predominance [11]. Most
Multiple fluid levels present within cystic cavi- patients with GCT complain of tenderness or
ties may be detected on T2-weighted axial pain at the affected site. The pain can be of
sequences. Multiple fluid levels and thin septa months’ duration and is sometimes accompanied
without nodularity are highly suggestive of by warmth, swelling, tenderness, or decreased
ABC. Postcontrast MR imaging reveals range of motion [37]. Approximately 50% of all
enhancement of the thin and nodular cyst walls GCTs occur in the knee. In the upper extremity,
and internal septa. in decreasing order of frequency, GCT occurs in
Lesion curettage and filling by graft, the radius (distal much more commonly than
cement, or bone substitute may provide good proximal), humerus (4–8% and proximal much
results, but there is a 10–30% risk of local more commonly than distal), phalanges, meta-
recurrence [29]. carpals, and ulna (distal much more commonly
Fig. 12.10 Giant-cell

tumor: 28-year-old
female with right-
shoulder pain for 6
weeks. Radiograph
demonstrates a lytic
lesion with a geographic
1B margin. Lesion
center is near the
physeal scar and extends
very close to the
subchondral bone plate.
Probable cortical
breakthrough is noted
medially (arrow)
than proximal) [37]. Lesions arise in long bones resembling a doughnut have been described in
in approximately 60% of cases and almost all approximately 50% of cases [11, 37]. GCT
extend to the subchondral bone [11]. most often reveals a low to intermediate signal
At radiograph, GCT of bone is most fre- on T1- and T2-weighted images (90% of cases).
quently a lytic lesion with a geographic 1B Postcontrast images most often demonstrate
(80–85%) pattern of destruction. Larger lesions heterogeneous enhancement [11].
may show expansile remodeling of the bone. Intralesional curettage is the mainstay of man-
The lesion arises eccentrically in the metaphy- agement for primary GCT of bone. The recur-
sis and expands through the adjacent epiphysis rence rate has declined to approximately 17%
to the subarticular plate [11, 37]. Periosteal with the use of adjuvant treatment such as liquid
reaction is uncommon without pathologic frac- nitrogen, phenol, hydrogen peroxide, and bone
ture. CT demonstrates similar findings to radi- cement [36]. Denosumab is a promising medical
ography, but is more sensitive for detecting treatment to prevent bone destruction and may
areas of cortical destruction and soft-tissue offer symptom and disease control for patients
extension (33–50%). Bone scintigraphy often with limited surgical options [38].
demonstrates increased radionuclide activity, A differential diagnosis for epiphyseal lesions
which may extend beyond the GCT to involve of the proximal humerus includes GCT, chondro-
nearby bones and may be valuable in detecting blastoma, subchondral cyst, Brodie’s abscess,
multicentric GCT. Intense uptake at the periph- Langerhans cell histiocytosis, and clear-cell
ery and diminished central activity in a pattern chondrosarcoma.
12.4 Malignant Bone Tumors in POEMS syndrome (polyneuropathy, organo-

megaly, endocrinopathy, monoclonal plasma-
12.4.1 Multiple Myeloma proliferative disorder, and skin changes) [11,
40]. The sensitivity of radiography versus bone
Multiple myeloma is a clonal neoplastic prolifera- scanning for detecting multiple myeloma has
tion of plasma cells. The process is usually multi- been reported from 75 to 91% for radiography
centric (polyostotic). A solitary lesion and 46 to 60% for scintigraphy [41, 42]. One of
(plasmacytoma) initially lacks systemic manifes- the most significant advantages of FDG-PET/CT
tations. Synonyms of multiple myeloma include imaging is its ability to distinguish between
myeloma, plasma cell myeloma, and Kahler dis- active multiple myeloma (FDG positive) and
ease. Multiple myeloma is the most frequent monoclonal gammopathy of undetermined sig-
malignant tumor occurring primarily in bone and nificance (MGUS) or smoldering disease [40].
accounts for 27% of biopsied bone tumors [13, Subtle lesions or lesions in areas of complex
26]. Myeloma is rare in patients younger than anatomy such as the spine may require cross-
40 years and most commonly presents in the sixth sectional imaging for detection. CT is more sen-
and seventh decades of life. Male involvement sitive than radiograph for revealing intraosseous
(68%) is more common than female [26]. extent, cortical disruption, and soft-tissue exten-
Myeloma is often associated with abnormal pro- sion. One negative aspect of CT is that it typi-
teins in the blood and urine and may result in cally shows persistent bone lesions throughout
amyloid deposition. Elevated serum calcium lev- the course of the disease and, unlike MRI and
els, anemia, or serum protein electrophoresis may FDG-PET/CT, it cannot assess continued activ-
suggest the diagnosis of myeloma before biopsy ity of myeloma in areas of prior bone destruc-
in a patient with a solitary lesion or unknown tion. MR imaging is more sensitive than CT or
diagnosis. The most common presenting symp- radiography in lesion detection. The marrow
tom is mild and transient pain, worse during the replacement on MR may be diffuse or focal.
day and increased by weight bearing noted in T1-weigthed sequences reveal low- signal-
75% of patients [39]. Malaise, fatigue, weight intensity lesions. Fluid-sensitive MR sequences
loss, fever, bone pain, and pathologic fracture are demonstrate lesions to be homogeneous and
other commonly encountered symptoms. high signal. Lesions generally show enhance-
Myeloma usually arises in bones that contain red ment on gadolinium-enhanced images.
marrow. Radiological evidence of skeletal The treatment of multiple myeloma may
involvement on the skeletal survey is seen in include chemotherapy, bisphosphonates, radia-
nearly 80% of myeloma patients, most commonly tion, biologic therapy, stem cell transplant, and
affecting the following sites: vertebrae in 66%, plasmapheresis. Reasons for surgical interven-
ribs in 45%, skull in 40%, shoulder in 40%, pelvis tion include an indeterminate lesion, spinal cord
in 30%, and long bones in 25% [40]. compression, and pathologic fracture.
Myeloma may present in a variety of radio-
graphic patterns. Polyostotic well-defined
lesions with a geographic 1B margin are the 12.4.2 Metastatic Disease
most frequent presentation. A pattern of diffuse
osteoporosis particularly in the spine may be The skeleton is the third most common site of
present and lead to vertebral compression frac- metastases. Metastases are most often located in
ture. Diffuse osteopenia as a result of multiple the red bone marrow. The presentation of a meta-
myeloma cannot be distinguished on radiographs static bone lesion is highly variable and lesions
from more common causes of osteopenia, such may resemble any malignant or benign primary
as senile and postmenopausal osteoporosis (enti- bone neoplasm, so it is usually prudent to include
ties noted in a similar age group). The least com- bone metastases in the differential diagnosis of
mon pattern is sclerosing myeloma (1%) present aggressive or multiple bone lesions in a patient
over the age of 40 years. Bone metastases are far 12.4.3 Osteosarcoma (Osteogenic
more common than primary bone tumors. It is Sarcoma)
estimated that 2900 new sarcomas of bone are
diagnosed in the United States each year. In Conventional intramedullary osteosarcoma
comparison 169,500 new cases of carcinoma of (Fig. 12.11) is a high-grade, malignant neoplasm
the lung and 193,700 new cases of breast carci- in which the neoplastic cells produce bone (oste-
noma are diagnosed [26]. Malignant bone tumors oid). Histologic patterns include osteoblastic
are metastatic in origin in approximately 70% of (82%), fibroblastic (7%), and chondroblastic
cases [11]. Metastatic bone lesions are biopsied (5%). Even if only a minority of the lesion is pro-
at least 35 times more frequently than primary ducing osteoid, it is designated an osteosarcoma.
bone tumors. Prostate, breast, kidney, lung, and It may be primary or secondary (if the underlying
thyroid (in order of decreasing frequency) make bone is altered by previous radiation, Paget dis-
up 80% of all metastatic skeletal lesions. Pain is ease, or bone infarct) [13]. Osteosarcoma is the
the most common symptom and present in up to most common primary malignant tumor of bone
67% of patients. Pathologic fracture and verte- in children and young adults and second only to
bral compression may occur. Breast carcinoma multiple myeloma overall. It accounts for approx-
is most commonly lytic (65%) followed by imately 15% of all primary bone tumors. Several
mixed lytic and blastic on radiography and subtypes of primary osteosarcoma have been
CT. Prostate carcinoma is the most common described, including intramedullary lesions (high
cause of bone metastases in men and 75% are grade, telangiectatic, low grade, small cell, osteo-
osteoblastic on radiography and CT. Lung can- sarcomatosis, and gnathic), surface lesions (intra-
cer patients have bone metastases in 15% of cortical, parosteal, periosteal, and high-grade
cases and the majority (80%) of lesions are lytic surface), and extraskeletal osteosarcoma. This
on radiography and CT. Renal cell carcinoma chapter focuses on conventional intramedullary
and thyroid carcinoma are frequently lytic and osteosarcoma. Patients in the age range of
highly vascular, with many lesions showing 15–25 years account for 75% of cases of conven-
prominent expansile remodeling of bone. Lytic tional intramedullary osteosarcoma. There is a
bone metastases may demonstrate geographic male-to-female ratio of 1.5–2:1 [46].
(usually 1B or 1C pattern), moth-eaten, or per- Osteosarcoma presents as an enlarging painful
meative margins. Lesions distal to the knees and mass that may be palpable. The pain is deep-
elbows (acral metastases) are unusual and likely seated and progressive and may be present for
bronchogenic lung carcinoma (also frequently several months before diagnosis [35]. High-grade
responsible for “cookie bite” lesions of the cor- intramedullary osteosarcoma most frequently
tex). Periosteal reaction is usually absent or lim- affects long bones (70–80% of cases), particu-
ited in response at sites of bone metastases. larly about the knee (50–55%). The humerus is
Prostate carcinoma, gastrointestinal (GI) malig- involved in 10–15% of cases [46].
nancies, and retinoblastoma are most likely to Evaluation of osteosarcoma should begin with
cause significant periosteal reaction. The radio- the radiograph. A mixed pattern of sclerosis and
nuclide bone scan is a good screening method lytic areas is most frequent. The majority
for detection of both lytic and sclerotic bone (approximately 90%) of osteosarcomas demon-
metastases. For evaluating marrow disease, MR strate a variable amount of fluffy, cloudlike opac-
is an established technique that is both more sen- ities within the lesion. Identifying osteoid matrix
sitive and specific than bone scintigraphy. mineralization and other aggressive features is
T1-weighted signal lower than skeletal muscle key to diagnosis. The lesion usually violates the
usually indicates abnormal marrow. FDG-PET is cortex without remodeling and demonstrates
used in the staging of malignancies, for their aggressive periosteal reaction (Codman triangle,
management, and for monitoring the response to laminated, hair-on-end, or sunburst patterns) and
therapy [11, 43–45]. soft-tissue masses are present in 80–90% of
a b c
Fig. 12.11 Osteosarcoma: 15-year-old female with right case). Note the significant soft-tissue component (curved
upper extremity mass. Radiograph (a) reveals a mixed arrow) and dark areas (arrow) corresponding to osteoid
pattern of sclerosis and lucent areas. Aggressive periosteal matrix. Whole-body scintigraphy (c) is performed to eval-
reaction is present within the soft-tissue component uate for distant metastases. The proximal humeral lesion
(arrow). Codman triangles are present distally (arrow- (curved arrow) shows radionuclide uptake greater than the
head). (b) Coronal T2-weighted (TR2700, TE76) anterior iliac spines. CT of the chest (not shown) should
sequence with fat saturation of the entire humerus is per- also be performed on the initial workup to evaluate for
formed to look for skip metastases (not present in this lung metastases
cases. Lesions are most frequently centered in the field of view to image the entire bone is essential
metaphysis (90%) of long bones and 75–90% of to identify “skip” metastases. Discontinuous or
lesions extend across the epiphyseal plate. Cross- skip metastases are seen in 1–25% of cases and
sectional imaging is essential for staging and appear separated from the primary tumor by nor-
preoperative planning. CT may help identify
mal intervening marrow but within the same bone
mineralized matrix that is not appreciable at radi- [47]. Areas of low signal intensity on both T1-
ography and chest CT is utilized to evaluate for and T2-weighted MR images are frequent and
lung metastases. At bone scintigraphy, significant represent mineralized matrix. Foci of central
uptake of radiotracer is seen on blood flow, blood hemorrhage (high signal intensity with all MR
pool, and delayed images. The major role of scin- pulse sequences) and areas of necrosis (low sig-
tigraphy is evaluating for distant and skip metas- nal intensity on T1-weighted images and high
tases. Both osseous and extraosseous metastatic signal intensity on T2-weighted MR images) are
diseases may be detected [46]. On MR imaging, common in both the intraosseous and soft-tissue
tumor is seen primarily as areas of intermediate tumor components. The lesion margins may be
signal intensity on TI-weighted images and as obscured by perilesional edema on MR images
areas of high signal intensity replacing the nor- obtained with water-sensitive pulse sequences
mal marrow on T2-weighted images. A large [46]. The use of contrast is valuable in monitoring
the response to chemotherapy. In responsive Primary chondrosarcoma is the third most com-
tumors, the intraosseous component may not mon primary malignant tumor of bone, constitut-
change in size, but the extraosseous component ing 20–27% of all primary malignant osseous
decreases. Contrast may assist in differentiating neoplasms [49]. Numerous types of primary
viable tissue from nonviable tissue [47]. chondrosarcomas have been described, including
The chemotherapy regimen may include conventional intramedullary, clear cell, juxtacor-
several or all of the following four drugs: doxoru- tical/periosteal, myxoid, mesenchymal, extraskel-
bicin, high-dose methotrexate with leucovorin- etal, and dedifferentiated chondrosarcoma. The
rescue, cisplatin, and ifosfamide. Preoperative conventional intramedullary chondrosarcoma is
(neoadjuvant) plus postoperative (adjuvant) poly- the most frequent type and is discussed in this
chemotherapy should be used. Surgery should be chapter [49]. Histologic grade is grade 1 (30%),
wide surgical resection and limb salvage or ampu- grade II (40%), or grade III (30%). Patients with
tation if salvage is not possible [48]. conventional chondrosarcoma most commonly
present in the fourth to fifth decades of life. There
is a male predilection of approximately 3:2.
12.4.4 Chondrosarcoma Clinical symptoms of chondrosarcoma are non-
specific, with pain being the most frequent,
Chondrosarcoma (Fig. 12.12) is a malignant occurring in at least 95% of patients. A palpable
tumor that produces cartilage matrix. Lesions soft-tissue mass or fullness may also be a pre-
that arise de novo are called primary chondrosar- senting symptom, described in 82% of patients
coma. A secondary chondrosarcoma may arise in [49]. The most common skeletal location for con-
an enchondroma, osteochondroma, Paget focus, ventional chondrosarcoma is the long bones (also
radiated bone, or other preexisting lesion. a common site for solitary enchondroma),
a b c
Fig. 12.12 Chondrosarcoma: 38-year-old female with (TR1800, TE80) demonstrates high signal, similar to water,
shoulder pain after heavy lifting at work. Radiograph (a) with lobular growth (curved arrow) and lower signal foci cor-
demonstrates a proximal humeral lesion with classic chon- responding to mineralized matrix (arrow). Whole-body scin-
droid matrix. The lesion shows greater than two-thirds end- tigraphy (c) reveals proximal humeral lesion uptake (arrow)
osteal scalloping (arrow). (b) Coronal T2-weighted sequence of radiotracer greater than the anterior iliac spines
accounting for approximately 45% of cases. The appears as low-to-intermediate signal intensity.
upper extremity is involved in 10–20% of cases, Entrapped areas of peripheral yellow marrow
with the proximal humerus being the most fre- may be seen as small speckled punctate regions
quent location [49]. of high signal intensity (trapped fat) on
Radiographs of conventional intramedullary T1-weighted MR images in long-bone intra-
chondrosarcoma typically demonstrate a mixed medullary chondrosarcomas (35% of lesions)
lytic and sclerotic appearance. The sclerotic foci but are much less common than in enchondro-
represent chondroid matrix mineralization and mas (65%). Fluid-sensitive MR images demon-
are seen in 60–78% of lesions. The characteris- strate lesion signal similar to fluid (in grade I
tic appearance of chondroid matrix is the lesions) and emphasize the lobular growth pat-
“ring-and-
arc” pattern of calcification. This tern [49]. Mineralized matrix reveals low signal
mineralized matrix may coalesce to form a more intensity on all MR pulse sequences. The con-
radiopaque flocculent pattern of calcification. trast enhancement pattern of conventional intra-
Higher grade chondrosarcomas contain rela- medullary chondrosarcoma is typically mild in
tively less extensive matrix mineralization. The degree and peripheral and septal in pattern (sim-
radiolucent component usually reveals geo- ilar to enchondroma) [49]. In one study, FDG-
graphic (1B or 1C) bone lysis and is multilobu- PET using the combination of SUV and
lated, directly corresponding to the lobular histopathologic tumor grade improved predic-
pattern of growth seen pathologically. More tion of outcome, allowing identification of
aggressive patterns of bone lysis (moth-eaten patients at high risk for local relapse or meta-
and permeative) may be seen with higher grade static disease [50].
conventional chondrosarcomas (grade III). Acceptable oncologic and functional results
Continued lesion growth leads to lobulated end- have been observed in patients with grade I chon-
osteal scalloping that eventually produces corti- drosarcoma treated with curettage and cryosur-
cal disruption (57% of long-bone lesions on gery alone, although local recurrence is not
radiographs) and a soft-tissue component (46% unusual if there is inadequate resection [49].
of long-bone lesions on radiographs). In the Features that favor the diagnosis of chondro-
authors’ experience, the depth of endosteal scal- sarcoma as compared to enchondroma in the long
loping at its most prominent focus is the best bones include the presence of pain, patient age
distinguishing feature between long-bone greater than the fourth decade of life, lesion size
enchondroma and chondrosarcoma. Low-grade greater than 4 cm, deeper than 2/3 endosteal scal-
chondrosarcoma demonstrates relatively slow loping, cortical thickening/remodeling, soft-tissue
growth. The cortex responds to this lobular extension, marrow edema surrounding the lesion
growth by attempting to maintain the lesion in on MR fluid-sensitive sequences, uptake of radio-
the medullary canal resulting in cortical expans- tracer usually greater than the anterior iliac crest
ile remodeling, cortical thickening, and perios- on whole-body bone scintigraphy, and presence
teal reaction (usually a less aggressive pattern). of hypermetabolic foci on FDG-PET [22]. MR
The majority (82%) of long-bone chondrosarco- imaging findings that support a diagnosis of high-
mas reveal marked increased radionuclide grade chondrosarcoma include intratumoral
uptake on bone scintigraphy compared with that hemorrhage and soft-tissue mass formation.

in the anterior iliac crest. CT allows optimal High-grade and dedifferentiated chondrosarco-
detection and characterization of chondroid mas frequently lose the common MR imaging
matrix mineralization, depth of endosteal scal- features often seen in low-grade chondrosarco-
loping, and soft-tissue extension. MR imaging mas of entrapped fat at the tumor margin, internal
provides the best method for depicting the and outer lobular architecture, characteristic
extent of marrow involvement by conven- peripheral and septal enhancement pattern after
tional intramedullary chondrosarcoma. On contrast administration, and high signal intensity
T1-weighted MR images, marrow replacement on water-sensitive sequences [22].
12.4.5 Ewing Sarcoma presenting symptoms include pain severe enough

to wake the patient (96%), palpable mass (61%),
The Ewing sarcoma family of tumors includes and intermittent fever (21%) [13]. The most com-
osseous Ewing sarcoma (Fig. 12.13), extraskele- mon affected bones are the femur (21% of cases),
tal Ewing sarcoma, primitive neuroectodermal ilium (12–13%), tibia (8–11%), humerus (10%),
tumor (PNET), and Askin tumor of the chest fibula (7–9%), ribs (8%), and sacrum (6%).
wall. Histologically, these lesions demonstrate While a diaphyseal location of osseous Ewing
crowded fields of small round blue cells [51]. sarcoma is often stressed, the majority of long-
Ewing sarcoma accounts for 6–8% of primary bone lesions are actually metadiaphyseal (44–
malignant bone tumors, and is the second most 59%) and pure diaphyseal lesions account for
common bone sarcoma of children and young only 33–35% of cases [51].
adults (after osteosarcoma). Ewing sarcoma At radiography, Ewing sarcoma of bone
accounts for approximately 3% of all pediatric reveals aggressive features, reflecting the high-
malignancies. Ewing sarcoma demonstrates a grade nature of this lesion. Bone destruction with
slight male predominance (1.5:1). Approximately a moth-eaten to permeative pattern is seen in
75% of patients are aged 10–25 years. Common 76–82% of lesions, and a wide zone of transition
is identified in 96% of lesions. Cortical destruc-
tion (19–42%) with associated soft-tissue exten-
sion (56–80%) is also common. Aggressive
periosteal reaction is frequent (58–84%) and is
usually either lamellated/onionskin (55%) or
spiculated (sunburst or hair-on-end pattern) [51].
Nuclear medicine studies show increased radio-
nuclide uptake at both bone scintigraphy and gal-
lium scanning. FDG-PET shows increased
metabolic activity in the primary lesion, with a
mean maximum standardized uptake value
(SUV) ranging from 5.3 (no metastases at pre-
sentation) to 11.3 [51]. The appearance of Ewing
sarcoma at CT is similar to radiographs, with
bone destruction and a large associated soft-
tissue mass (96% of cases). The cortical involve-
ment may have a striated appearance within the
cortex without focal destruction and continuity
between the medullary and soft-tissue compo-
nent on CT and MR. The soft-tissue component
is commonly homogeneous and similar in attenu-
ation to that of skeletal muscle (98% of cases).
MR imaging of Ewing sarcoma of bone demon-
strates bone marrow replacement (100%) and
cortical destruction (92%), with an associated
soft-tissue mass in 96% of cases. The signal
intensity of Ewing sarcoma is usually homoge-
neous (73%) and intermediate signal (95%) on
Fig. 12.13 Ewing sarcoma: 20-year-old male with T1-weighted images. On T2-weighted images,
shoulder pain. Radiograph demonstrates a diaphyseal
lesion with moth-eaten to permeative (arrowhead) destruc-
Ewing sarcoma is typically homogeneous (86%)
tion of the cortex and medullary space. There is an aggres- and low to intermediate in signal intensity (68%).
sive periosteal reaction (arrow) Contrast enhancement is noted in all cases and is
usually either diffuse or peripheral nodular in joints (90%) have coexisting degenerative
pattern [51]. change. The knee is much more commonly
Therapy primarily involves initial use of neo- involved with rare case reports of lipoma arbore-
adjuvant chemotherapy for the purpose of elimi- scens involving the shoulder. Radiographs often
nating micrometastases and reducing the size of show soft-tissue swelling around the joint that
the primary tumor. Chemotherapy of Ewing sar- may be radiolucent if the lesion is sufficiently
coma includes neoadjuvant (before local control) large. CT demonstrates hypertrophied fatty
and adjuvant (after local control) therapy over fronds of low attenuation. MR imaging reveals
approximately 6 months to 1 year. Chemotherapy prominent frond-like lipomatous masses within
agents commonly used in the treatment of Ewing the involved joint. Signal intensity is consistent
sarcoma include vincristine, doxorubicin, and with fat (high T1, high T2, low T2 fat-suppressed-
cyclophosphamide alternated with ifosfamide FS-MR images). Enhancement may be seen in
and etoposide. Surgical treatment of the Ewing the adjacent inflamed synovium [1].
sarcoma is often the primary method of local Pigmented villonodular synovitis (PVNS)
control [51]. (Fig. 12.14a) represents a benign, hypertrophic
The differential diagnosis of a moth-eaten/ synovial process characterized by villous, nodu-
permeative bone lesion with no matrix mineral- lar, and villonodular proliferation and pigmenta-
ization and aggressive periosteal reaction would tion from hemosiderin [52]. This lesion most
include Ewing tumor, lymphoma, metastatic often presents in the third and fourth decades.
lesion, malignant fibrous histiocytoma (MFH)/ There is an equal sex predilection. Patients most
fibrosarcoma of bone, Langerhans cell histiocy- often present with a slowly growing mass. Joint
tosis, osteomyelitis, and osteosarcoma (10% of involvement with decreasing frequency includes
osteosarcoma may fail to demonstrate matrix). the knee (75–80% of cases), hip, ankle, shoulder,
The presence of a prominent soft-tissue compo- and elbow [1]. Radiographs may be normal, but
nent on cross-sectional imaging would favor erosive bone lesions may develop in tight joints
Ewing tumor, lymphoma, MFH/fibrosarcoma of such as the shoulder (75%) and hip (93%).
bone, and osteosarcoma. Lack of soft-tissue mass Ultrasound demonstrates a large complex intra-
and presence of marked edema and fluid collec- articular mass containing fluid and septations.
tions would favor osteomyelitis. CT shows an intra-articular soft-tissue mass with
increased attenuation (because of the hemosid-
erin) relative to muscle. Lower attenuation joint
12.5 Intra-articular Lesions effusion may be present [52]. If erosive lesions
are present, CT most frequently reveals sharply
There is a limited differential diagnosis for intra- defined lesions with sclerotic margins. The MR
articular lesions. The lesions most likely to be appearance of PVNS is characteristic with a het-
encountered in the shoulder include lipoma arbo- erogeneous synovial based mass. T1-weighted
rescens, synovial chondromatosis, pigmented images show signal intensity similar to or less
villonodular synovitis, and rice bodies secondary than skeletal muscle. Low signal intensity pre-
to an inflammatory synovial process. dominates on T2-weighted MR images, owing to
Lipoma arborescens (LA) is thought to be a the preferential shortening of T2 relaxation time
reactive process and is frequently associated with caused by hemosiderin, an effect that is accentu-
degenerative joint changes or chronic rheumatoid ated at higher magnet field strength. The charac-
arthritis. LA is composed of villous lipomatous teristic most suggestive of PVNS is enlargement
proliferation of the synovial membrane resulting of the low-signal-intensity areas (“blooming”)
in prominent fatty fronds. Associated joint effu- caused by magnetic susceptibility artifact on
sion is present in all cases and most involved gradient- echo (GRE) sequences [52]. Intense
a b
Fig. 12.14 Intra-articular lesions: (a) Pigmented villon- Note the osseous erosions (arrowheads) of the humeral
odular synovitis demonstrated on axial T2-weighted head. (b) Synovial chondromatosis on AP radiograph.
sequence with fat saturation. The mass reveals a predomi- Note multiple small mineralized nodules of similar size
nantly low-signal-intensity lesion (arrows) with preferen- within the axillary recess (curved arrow)
tial shortening of T2 relaxation time caused by hemosiderin.
contrast enhancement is typical secondary to sig- modality to both detect and characterize calcifi-
nificant vascularity. Synovectomy is the treat- cation and low-attenuation nonmineralized
ment of choice [1]. regions from associated joint fluid [53]. CT is
Primary synovial chondromatosis particularly useful for identifying the characteris-
(Fig. 12.14b) is a benign neoplastic process with tic ring-and-arc or punctate mineralization and
hyaline cartilage nodules in the subsynovial tis- the multiplicity of nodules in cases for which
sue of a joint, tendon sheath, or bursa. It typically radiographic findings are normal. The most fre-
affects patients in the third to fifth decades of life. quent MR appearance is a lobulated intra-
Men are affected two to four times more fre- articular lesion with homogeneous intermediate
quently than women [53]. Clinical symptoms signal intensity similar to that of muscle on
typically include pain, swelling, and decreased T1-weighted images, high signal intensity on
range of motion of the affected joint. The knee is T2-weighted images, and focal areas of low sig-
the most frequently affected articulation (50– nal intensity on all pulse sequences representing
65% of cases) followed by the hip, elbow, shoul- mineralization. The contrast enhancement pat-
der, and ankle [53]. Radiographs reveal multiple tern of primary synovial chondromatosis is typi-
intra-articular calcified bodies in 70–95% of cal of hyaline cartilage lesions, which demonstrate
cases, which are typically distributed evenly a characteristic peripheral and septal enhance-
throughout the joint. The calcified lesions are ment pattern [53]. The treatment of choice for
typically innumerable and very similar in shape. primary synovial chondromatosis is synovec-
In long-standing disease, individual chondral tomy and surgical resection. The recurrence rate
bodies may coalesce to form a larger, conglomer- for intra-articular disease in larger series appears
ate, mineralized mass. CT is the optimal imaging to range from 3% to 23% [53].
12.6 Benign Soft-Tissue Tumors ommend placing a fiducial marker over superfi-
cial lesions, and position the patient so the lesion
12.6.1 Lipoma is not compressed, and comparing the area with
the contralateral unaffected side [54]. Deep lipo-
The lipoma (Fig. 12.15) is a benign neoplasm mas include intramuscular and intermuscular
composed of mature adipose tissue. It is the most lipomatous lesions. These lesions occur most
common neoplasm of soft tissue and represents commonly in patients aged 20–60 years. Men are
about 50% of all soft-tissue tumors. The inci- affected more frequently than women. The
dence of lipoma is approximately 2.1% [54]. lesions are located in the shoulder in 12% of
Most lipomas are discrete soft-tissue masses cat- cases. The size range of lipoma is large, and
egorized by the anatomic location as superficial lesions can measure up to 20 cm [54]. Both
(subcutaneous) or deep lesions. Deep lesions are superficial and deep lipomas often present with a
much less common and account for approxi- painless slow-growing soft-tissue mass. Lipomas
mately 1% of lipomas but are imaged more fre- may be multiple in 5–15% of patients [54]. In the
quently [54]. Lipomas are rare in the first two authors’ experience, deep lipomas involving the
decades of life [54]. Superficial lipomas typically extremity are most commonly intramuscular
present in the fifth to seventh decades, with 80% lesions [55].
of lesions in patients aged 27–85 years, and no Imaging evaluation is diagnostic in up to 71%
clear sex predilection [54]. Most lesions are of cases [55]. Radiographs of superficial lipoma
small, with 80% measuring less than 5 cm. may be unremarkable or demonstrate a mass of
Superficial lipomas are most commonly located fat density. Deep lipoma may reveal a mass with
in the trunk followed by the shoulders, upper density similar to subcutaneous fat. The sono-
arm, and neck. These lesions are unusual in the graphic appearance of superficial lipoma is usu-
hands and feet [54]. The superficial lipoma is ally an elliptical mass parallel to the skin surface.
often difficult to distinguish from surrounding The lesion is hyperechoic relative to the adjacent
subcutaneous tissue, particularly if the lesion is skeletal muscle and may contain linear echogenic
unencapsulated. For this reason, the authors rec- lines at right angles to the ultrasound beam. They
have no increase through transmission and com-
press with moderate pressure on the transducer
[1]. On CT, lipomas appear as a homogeneous
mass with attenuation (−65 to −120 Hounsfield
units) similar to the subcutaneous fat. The lesion
fibrous capsule shows attenuation similar to skel-
etal muscle when present [51]. Lesions are usu-
ally well defined, but lesions may occasionally
have infiltrating margins. Lipomas on MR imag-
ing most commonly demonstrate signal isoin-
tense to subcutaneous fat on all pulse sequences
with high signal on T1-weighted and T2-weighted
sequences and thin (<2 mm) septations. However,
28–30% have been reported to have thick septa or
nodularity similar to liposarcoma [54]. The
authors find it useful to compare the degree of
lesion septation to the adjacent normal subcuta-
neous fat. Lipomas typically reveal septations of
Fig. 12.15 Subcutaneous lipoma: 38-year-old female
with shoulder mass. Axial T1-weighted sequence (TR500,
no greater thickness or number than this normal
TE9.9) reveals an encapsulated subcutaneous lesion of tissue. We believe that the use of this comparison
high signal (curved arrow) can reduce the number of lipomatous lesions that
are reported as well-differentiated liposarcoma

by imaging. Intramuscular lipomas may have
irregular margins, which interdigitate with the
adjacent skeletal muscle referred to as infiltrating
lipoma. In a 2003 study of 58 lipomatous lesions,
lipomas showed no enhancement of septa in 58%
of cases and moderate enhancement of the septa
in 37% [54]. The fibrous capsule of the lesion
often enhances. Calcifications are reported in
11% of benign fatty lesions but are more com-
mon in malignant fatty tumors [54].
Treatments described in the literature include
steroid injection, liposuction, and surgical exci-
sion [56]. The local recurrence rate of these
lesions is approximately 4%.
The differential diagnosis for a lipomatous
lesion with mild complexity includes lipoma, Fig. 12.16 Angiomatosis: 43-year-old female with osse-
angiolipoma, myolipoma, chondroid lipoma, ous abnormality of the scapula noted on chest radiograph.
lipoblastoma, spindle cell/pleomorphic lipoma, T2-weighted image with fat saturation (TR2181, TE60)
shows a large lesion with features of serpentine vascular
hibernoma, and well-differentiated liposarcoma.
channels (arrowheads) involving multiple compartments
and the scapula (arrow)
12.6.2 Hemangioma
Radiographs may be normal or may show a
The authors prefer to combine hemangiomas and soft-tissue mass and phleboliths. Reactive and
vascular malformations into one category for pressure changes of bone may occur, particu-
discussion. Hemangiomas and/or vascular mal- larly when lesions are adjacent to bone, and
formations are among the most frequent tumors include a benign periosteal reaction and corti-
to involve the soft tissue and comprise 7% of all cal scalloping (25–30% of cases). The unen-
benign tumors. Hemangioma is the most com- hanced CT shows a soft-tissue density mass
mon tumor in infancy and childhood. It has been with or without phleboliths. US reveals a com-
estimated that 1–2% of the general population plex mass with acoustic shadowing if phlebo-
and 10% of Caucasians are affected [57]. liths are present. MR imaging features are often
Hemangiomas are more common in females characteristic. The lesion may be well defined
with a 3:1 ratio. Lesions may enlarge dramati- or infiltrative. Lesions demonstrate low-to-
cally during pregnancy. Soft-tissue hemangioma intermediate signal intensity on T1-weighted
may be superficial or deep, and deep lesions are images. There may be associated fatty over-
most frequently intramuscular. Angiomatosis growth due to chronically ischemic muscle in
(Fig. 12.16) represents diffuse infiltration by deep-seated lesions, which follows subcutane-
hemangiomas or lymphangiomas with imaging ous adipose signal. Vascular elements show
characteristics similar to solitary lesions except high signal intensity on T2-weighted images
for the distribution with involvement of multiple and are typically serpentine in morphology.
soft-tissue planes (involving several compart- Enhancement is prominent, and feeding vessels
ments) and prominent longitudinal extension. may be evident. In our experience, approxi-
The clinical presentation is often as a painful mately 90% of deep hemangiomas reveal these
lesion that intermittently changes in size. The pathognomonic features of serpentine vascular
pain associated with intramuscular hemangio- channels and fat overgrowth and do not require
mas is often vague and related to exercise. biopsy for diagnosis.
Management of cavernous hemangioma is on both T1- and T2-weighted images [54].

dependent on the presence or absence of symp- Immature lesions with marked cellularity reveal
toms. Treatment of these vascular lesions ranges higher signal intensity on long TR images. In our
from observation, medical therapy, percutaneous experience, these immature lesions are also asso-
ablation, or surgical excision. ciated with a higher local recurrence rate after
resection. Relatively mature hypocellular areas
with abundant collagen reveal lower signal inten-
12.6.3 Fibromatosis sity on T1- and T2-weighted sequences often in a
band-like morphology (up to 86% of cases) [54].
The deep fibromatosis that commonly involves Primary surgery with negative surgical mar-
the shoulder is extra-abdominal fibromatosis or gins is the most successful primary treatment
desmoid-type fibromatosis. These lesions are modality for desmoid tumors. Radiation therapy
benign but intermediate in grade with no malig- may be used as a treatment for recurrent disease
nant potential. Fibromatoses are most common in or as primary therapy to avoid mutilating surgical
the second and third decades, with a peak inci- resection. Pharmacologic therapy with antiestro-
dence in the ages between 25 and 40 years. Lesion gens and prostaglandin inhibitors may also be
incidence is approximately 2–4 people per mil- used [59]. A new treatment with sorafenib is also
lion with less than 5% seen in the pediatric age being employed [60].
group. There is a female predilection in younger A reasonable differential diagnosis for soft-
patients, which equalizes in older populations tissue lesions with areas of low signal intensity
[54]. Desmoid-type fibromatosis often presents as on T1- and T2-weighted sequences includes
a deep, firm, and poorly circumscribed soft-tissue desmoid- type fibromatosis, densely calcified
mass, which is slow growing and painless. The masses, pigmented villonodular synovitis/giant-
most common locations of extra-abdominal fibro- cell tumor of tendon sheath (GCTTS), granular
matosis are the shoulder/upper arm (28%), chest cell tumor, and MFH/fibrosarcoma.
wall/paraspinal region (17%), thigh (12%), and
head and neck (10–23%) [54].
Radiographs are usually normal. On US, 12.7 Malignant Soft-Tissue
lesions are hypoechoic and may be ill defined or Tumors
well defined. Similar to MR, the fascial tail sign
may be noted on US [58]. On CT, the lesion is a Soft-tissue sarcomas occur in the upper extremity
nonspecific soft-tissue mass. Unless outlined by in approximately 33% of all cases [61]. The most
fat, the margins of the lesion are poorly defined. common soft-tissue sarcoma in adults is undif-
The lesion attenuation is variable and may be ferentiated pleomorphic sarcoma (UPS, formerly
higher, similar to, or lower than skeletal muscle called MFH), which occurs most often in older
[58]. MR imaging is the optimal modality for adults (50–70 years) and 25% occur in the upper
evaluation of deep fibromatosis because of its extremity. Lesions are typically seen as an intra-
superior soft-tissue contrast. Lesions are usually muscular mass with low-to-intermediate signal
centered intermuscular and invasion of the sur- intensity on T1-weighted images and intermedi-
rounding muscle is frequent. Lesion margins are ate-to-high signal on T2-weighted images. The
equally distributed between well-defined or irreg- lesions are heterogeneous on all pulse sequences
ular infiltrative. Linear extension along fascial reflecting variable amounts of collagen, myxoid
planes (fascial tail sign is seen in up to 80% of tissue, necrosis, and hemorrhage [62].
cases) is a common manifestation. The signal Liposarcoma is the second most common soft-
intensity of desmoid-type fibromatosis is variable, tissue sarcoma [62]. The well-differentiated lipo-
reflecting the relative amounts of collagen and sarcoma is the most common subtype of
degree of cellularity of the lesion. The most com- liposarcoma and 14% occur in the upper extrem-
mon MR appearance of desmoid-type fibromato- ity [62]. The imaging characteristics are very
sis on MR imaging is intermediate signal intensity similar to lipoma described earlier. The signifi-
cant nonadipose components in well-12.8 Myxoid Soft-Tissue Lesions

differentiated liposarcoma are seen as prominent
thick septa greater than 2 mm and focal nodular Myxoid soft-tissue lesions are a heterogeneous
regions usually less than 2 cm in size. The septa- group of benign and malignant mesenchymal
tions within a liposarcoma are usually thicker and tumors with an abundance of extracellular mucoid
more numerous than the septa within the normal material. These lesions may mimic cysts on radio-
adjacent subcutaneous tissue. Synovial sarcoma logic evaluation (low attenuation on CT, fluid-like
is a soft-tissue malignancy typically occurring in high T2 on MR) because of the high lesion water
young adults (15 and 35 years). It accounts for content. The differential diagnosis of a soft-tissue
approximately 5–10% of soft-tissue sarcomas lesion with signal characteristics and attenuation
with an equal male and female predominance. of fluid include the benign myxoid lesions intra-
Synovial sarcoma may be associated with faint muscular myxoma, synovial cyst, bursa, ganglion,
soft-tissue calcifications, a juxta-articular loca- and benign peripheral nerve sheath tumor, includ-
tion, and a high metastatic rate. These lesions ing neurofibroma and schwannoma. Malignant
may demonstrate the “triple sign” (areas that are myxoid entities include myxofibrosarcoma (for-
hyperintense, isointense, and hypointense on merly myxoid MFH), myxoid liposarcoma, and
T2-weighted MR) or the “bowl of grapes” (mul- myxoid chondrosarcoma [63].
tiloculated with numerous septa) appearance
[62]. Fibrosarcoma, leiomyosarcoma, rhabdo-
myosarcoma, dermatofibrosarcoma protuberans, 12.9 Tumorlike Conditions
clear-cell sarcoma, and epithelioid sarcoma (most
common sarcoma of the distal upper extremity) 12.9.1 Myositis Ossificans
are less common soft-tissue malignancies that
may be encountered in the shoulder. Myositis ossificans (heterotopic ossification
Soft-tissue malignancies tend to grow push- within muscle) (Fig. 12.17) is the most common
ing against adjacent structures and form a pseu- bone-forming lesion of the soft tissues. The ante-
docapsule as they enlarge, particularly when rior musculature of the thigh and arm is most fre-
deep-seated. The pseudocapsule consists of quently involved. Many patients (approximately
compressed fibrous connective tissue, normal 40%) have no history of trauma, and the diagno-
tissue, vascularization, and inflammatory reac- sis may not be suspected clinically [64].
tion. Malignant lesions tend to respect anatomic The initial radiographs may show soft-tissue
compartments and fascial borders until late in fullness without calcification. Peripheral calcifica-
their course [57]. Heterogeneous signal may rep- tions can be recognized on plain radiographs by the
resent mixed tissue types, necrosis, or hemor- third week, although their appearance may vary
rhage within the lesion. Only a minority (5%) of from 11 days to 6 weeks largely depending on
benign soft-tissue tumors are greater than 5 cm patient age (earlier in younger patients) [64].
in diameter and about 1% of benign lesions are Calcification is also present in some soft-tissue sar-
deep [57]. Malignant lesions may show increased comas (soft-tissue osteosarcoma, soft-tissue chon-
vascularity at the periphery and high interstitial drosarcoma, synovial sarcoma), but is noted
pressure at their center leading to a high rim-to- diffusely throughout the tumor. In c ontradistinction,
center differential enhancement ratio [62]. In myositis ossificans typically demonstrates a periph-
general, well-defined, smooth margins, homog- eral pattern (zone phenomena) of calcification that
enous signal intensity, and small size are seen becomes more evident as the heterotopic ossifica-
with benign lesions and heterogeneous signal tion matures. CT is more sensitive than radiography
and large size are indications of malignant for identifying early mineralization and central low-
lesions. However, unless a specific diagnosis can attenuation zone [64]. MR reveals heterogeneous
be determined, a lesion should be considered low signal intensity on T1-weighted images, hetero-
indeterminate and biopsy should be considered geneous high signal intensity on T2-weighted
for definitive diagnosis. images, and enhancement after contrast. The sig-
a b
Fig. 12.17 Myositis ossificans: 12-year-old male with synovial sarcoma. Myositis ossificans shown on an axial
left posterior arm mass and 4 months of pain after trauma. CT (b) is distinguished by the typical peripheral pattern
Radiograph (a) reveals a highly mineralized soft-tissue (zone phenomena) of calcification (curved arrow) that
lesion (arrow). Differential diagnosis would include soft- becomes more evident as the lesion matures
tissue osteosarcoma, soft-tissue chondrosarcoma, and
nificant soft-tissue edema surrounding myositis

ossificans during the early stages tends to be promi-
nent on CT and MR and is the key to discriminating
this lesion from soft-tissue tumors, which usually
have little or no surrounding edema [64]. On MR
imaging, the calcification is difficult to recognize
and the edema may simulate an infiltrative mass.
12.9.2 Paget Disease of Bone
The origin of Paget disease (Fig. 12.18) is

unclear, although evidence suggests that an infec-
tious agent (possibly viral) may be the cause.
Paget disease is frequently a polyostotic disorder
with increased bone turnover. It is most common
in people of northwestern European origin and in
countries with a large representation by descen-
dants of British emigrants, such as Australia and
New Zealand. The prevalence of Paget disease
seems to be decreasing in recent decades. It is
common in the older population, with an inci-
dence as high as 3–4% in patients older than
50 years [65]. Paget is rarely diagnosed in those Fig. 12.18 Paget disease: 64-year-old female with patho-
younger than 40 years. The most common pre- logic fracture (arrow) through Paget disease. The mixed
sentation of Paget disease is of an incidental find- phase of Paget demonstrates the characteristic radio-
ing. It may also present with dull pain not related graphic manifestations of osseous expansion and cortical
and trabecular thickening
to activity pain, tenderness, and increased warmth resection. Failure to do so may result in the
(related to lesion hypervascularity). Long- biopsy tract within an anatomic region needed
standing disease may be associated with bone for limb-sparing surgery. The radiograph is the
deformity (most often the tibia), accelerated first and most important diagnostic tool in eval-
osteoarthritis (particularly in the hips), and neu- uating a bone tumor and considering a differen-
rologic symptoms. Pathologic fractures may tial diagnosis. Close evaluation of a bone lesion
occur. Secondary sarcoma (usually osteosar- margin and periosteal reaction can reveal if the
coma) is rare (1% of cases) [65]. lesion is slow growing or aggressive. Geographic
Frequent anatomic areas of involvement 1A and 1B margins and solid or buttressing
include the skull (25–65% of cases), the spine periosteal reaction suggest a less aggressive
(30–75%), the pelvis (30–75%), and the proxi- lesion. It would be very uncommon for a malig-
mal long bones (25–30%). nant lesion to have a sclerotic margin (geo-
The early phase of Paget disease is character- graphic 1A) without prior treatment. Geographic
ized by osteolysis on radiographs. In the long 1C, moth-eaten or permeative margins and
bones, the osteolysis begins as a subchondral Codman triangle, onionskin, hair on end, and
area of lucency with an advancing wedge of oste- sunburst periosteal reaction suggest a more
olysis often demonstrating a characteristic sharp aggressive lesion behavior. Identifying the pres-
radiolucent margin without sclerosis likened to a ence of osteoid or chondroid matrix mineraliza-
“blade of grass” or “flame” shape. In the mixed tion can help limit and improve your differential
phase of Paget (the majority of cases), the charac- diagnosis. Features such as deep endosteal scal-
teristic manifestations seen radiographically are loping, cortical thickening/remodeling, and
coarsening and thickening of the trabecular pat- soft-tissue extension favor the diagnosis of
tern and cortex. In the long bones and pelvis, pro- chondrosarcoma over enchondroma. The peri-
gression to the blastic phase results is areas of osteal chondroma is not a common lesion, but
bone sclerosis that may be extensive, obscuring 50% present in the shoulder. ABC may develop
areas of previous trabecular thickening. Bone secondarily to several primary bone lesions.
enlargement is prominent in the blastic phase. Multiple myeloma is the most frequent malig-
Bone scintigraphy typically demonstrates marked nant tumor occurring primarily in bone and
increased uptake of radionuclide in all phases of most often has a polyostotic geographic 1B pre-
Paget disease. CT and MR imaging often show sentation. Myositis ossificans may mimic a min-
changes similar to those seen radiographically in eralized soft-tissue sarcoma such as soft-tissue
noncomplicated Paget disease with maintenance osteosarcoma, soft-tissue chondrosarcoma, and
of yellow marrow, osseous expansion, and corti- synovial sarcoma. The key to make this diagno-
cal and trabecular thickening. sis is recognizing the peripheral pattern (zone
Medical treatment with bisphosphonates and phenomena) of calcification. Lipoma is the most
calcitonin analogues may be useful for meta- common neoplasm of soft tissue and repre-
bolically active disease, in preparation for sents about 50% of all soft-tissue tumors.
orthopedic surgery, or patients in a state of Subcutaneous lipoma may be difficult to iden-
hypercalcemia or hypercalciuria. tify on MR without the placement of a fiducial
marker over the perceived mass before imaging.
Features that favor a malignant rather than
12.10 Summary benign soft-tissue tumor are lesion size greater
than 5 cm, heterogeneous appearance, and a
It is vital to include compartmental anatomy high rim-to-center differential enhancement
when describing a bone or soft-tissue tumor to ratio. Unless a specific diagnosis can be deter-
assist in local staging. Before biopsying a bone mined, a soft-tissue lesion should be considered
or soft-tissue tumor, it is advisable to discuss indeterminate and biopsy should be considered
your approach with the surgeon performing the for definitive diagnosis.
References measurement of cartilage cap at CT and MR imaging.

Radiology. 2010;255(3):857–65.
20. Robbin MR, Murphey MD. Benign chondroid
1. Kransdorf MJ, Murphey MD. Imaging of soft tissue
neoplasms of bone. Semin Musculoskelet Radiol.
tumors. 3rd ed. Philadelphia, PA: Wolters Kluwer,
2000;4(1):45–58.
Lippincott Williams & Wilkins; 2013.
21. Robinson P, White LM, Sundaram M, et al.
2. Anderson MW, Temple HT, Dussault RG, et al.
Periosteal chondroid tumors: radiologic evaluation
Compartmental anatomy: relevance to staging
with pathologic correlation. AJR Am J Roentgenol.
and biopsy of musculoskeletal tumors. AJR Am J
2001;177(5):1183–8.
Roentgenol. 1999;173(6):1663–71.
22. Logie CI, Walker EA, Forsberg JA, et al.
3. Madewell JE, Ragsdale BD, Sweet DE. Radiologic
Chondrosarcoma: a diagnostic imager's guide to
and pathologic analysis of solitary bone lesions.
decision making and patient management. Semin
Part I: internal margins. Radiol Clin N Am.
Musculoskelet Radiol. 2013;17(2):101–15.
1981;19(4):715–48.
23. Flemming DJ, Murphey MD. Enchondroma and
4. Miller TT. Bone tumors and tumorlike conditions:
chondrosarcoma. Semin Musculoskelet Radiol.
analysis with conventional radiography. Radiology.
2000;4(1):59–71.
2008;246(3):662–74.
24. Jee WH, Choe BY, Kang HS, et al. Nonossifying
5. Moser RPJ, Madewell JE. An approach to primary
fibroma: characteristics at MR imaging with patho-
bone tumors. Radiol Clin N Am. 1987;25(6):1049–93.
logic correlation. Radiology. 1998;209(1):197–202.
6. Ragsdale BD, Madewell JE, Sweet DE. Radiologic
25. Arata MA, Peterson HA, Dahlin DC. Pathological
fractures through non-ossifying fibromas. Review of
Part II: periosteal reactions. Radiol Clin N Am.
the Mayo Clinic experience. J Bone Joint Surg Am.
1981;19(4):749–83.
1981;63(6):980–8.
7. Sweet DE, Madewell JE, Ragsdale BD. Radiologic
26. Unni KK. Dahlin’s bone tumours. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2010.
Part III: matrix patterns. Radiol Clin N Am.
27. Fitzpatrick KA, Taljanovic MS, Speer DP, et al.
1981;19(4):785–814.
Imaging findings of fibrous dysplasia with histo-
8. Kransdorf MJ, Stull MA, Gilkey FW, et al. Osteoid
pathologic and intraoperative correlation. AJR Am J
osteoma. Radiographics. 1991;11(4):671–96.
Roentgenol. 2004;182(6):1389–98.
9. Dahlin DC, Unni KK. Dahlin's bone tumors. 4th ed.
28. Capanna R, Campanacci DA, Manfrini M. Unicameral
Springfield, Ill: Lippincott Williams & Wilkins; 1987.
and aneurysmal bone cysts. Orthop Clin North Am.
10. Huvos AG. Bone tumors, diagnosis, treatment, and
1996;27(3):605–14.
prognosis. Philadelphia, PA: Saunders; 1979.
29. Mascard E, Gomez-Brouchet A, Lambot K. Bone
11. Greenspan A, Jundt G, Remagen W. Differential diag-
cysts: unicameral and aneurysmal bone cyst. Orthop
nosis in orthopaedic oncology. 2nd ed. Philadelphia,
Traumatol Surg Res. 2015;101(1 Suppl):S119–27.
PA: Lippincott Williams & Wilkins; 2007.
30. Cohen J. Simple bone cysts. Studies of cyst fluid in
12. Rosenthal DI, Hornicek FJ, Wolfe MW, et al.
six cases with a theory of pathogenesis. J Bone Joint
Percutaneous radiofrequency coagulation of osteoid
Surg Am. 1960;42-A:609–16.
osteoma compared with operative treatment. J Bone
31. Dormans JP, Sankar WN, Moroz L, et al. Percutaneous
Joint Surg Am. 1998;80(6):815–21.
intramedullary decompression, curettage, and grafting
13. Fletcher CDM. World Health Organization;
with medical-grade calcium sulfate pellets for unicam-
International Agency for Research on Cancer. WHO
eral bone cysts in children: a new minimally invasive
classification of tumours of soft tissue and bone.
technique. J Pediatr Orthop. 2005;25(6):804–11.
Lyon: IARC Press; 2013.
32. Jaffe H, Lichtenstein L. Solitary unicameral bone
14. Qasem SA, DeYoung BR. Cartilage-forming tumors.
cyst: with emphasis on the roentgen picture, the
Semin Diagn Pathol. 2014;31(1):10–20.
pathologic appearance and the pathogenesis. Arch
15. Dahlin DC, Ivins JC. Benign chondroblastoma. A
Surg. 1942;44(6):1004–25.
study of 125 cases. Cancer. 1972;30(2):401–13.
33. Reynolds J. The "fallen fragment sign" in the
16. Braunstein E, Martel W, Weatherbee L. Periosteal
diagnosis of unicameral bone cysts. Radiology.
bone apposition in chondroblastoma. Skelet Radiol.
1969;92(5):949–53.
1979;4(1):34–6.
34. Kadhim M, Thacker M, Kadhim A, et al. Treatment
17. James SL, Panicek DM, Davies AM. Bone marrow
of unicameral bone cyst: systematic review and meta
oedema associated with benign and malignant bone
analysis. J Child Orthop. 2014;8(2):171–91.
tumours. Eur J Radiol. 2008;67(1):11–21.
35. Fletcher CDM, Unni KK, Mertens F. World Health
18. Murphey MD, Choi JJ, Kransdorf MJ, et al. Imaging
Organization; International Agency for Research on
of osteochondroma: variants and complications with
Cancer. Pathology and genetics of tumours of soft tis-
radiologic-pathologic correlation. Radiographics.
sue and bone. Lyon: IARC Press; 2002.
2000;20(5):1407–34.
36. Raskin KA, Schwab JH, Mankin HJ, et al. Giant
19. Bernard SA, Murphey MD, Flemming DJ, et al.
cell tumor of bone. J Am Acad Orthop Surg.
Improved differentiation of benign osteochondromas
2013;21(2):118–26.
from secondary chondrosarcomas with standardized
37. Moser RPJ, Kransdorf MJ, Gilkey FW, et al. From the 52. Murphey MD, Rhee JH, Lewis RB, et al. Pigmented
archives of the AFIP. Giant cell tumor of the upper villonodular synovitis: radiologic-pathologic correla-
extremity. Radiographics. 1990;10(1):83–102. tion. Radiographics. 2008;28(5):1493–518.
38. Xu SF, Adams B, Yu XC, et al. Denosumab and giant 53. Murphey MD, Vidal JA, Fanburg-Smith JC,
cell tumour of bone-a review and future management et al. Imaging of synovial chondromatosis with
considerations. Curr Oncol. 2013;20(5):e442–7. radiologic-pathologic correlation. Radiographics.
39. Dimopoulos MA, Moulopoulos LA, Maniatis A, et al. 2007;27(5):1465–88.
Solitary plasmacytoma of bone and asymptomatic 54. Walker EA, Fenton ME, Salesky JS, et al. Magnetic
multiple myeloma. Blood. 2000;96(6):2037–44. resonance imaging of benign soft tissue neoplasms in
40. Healy CF, Murray JG, Eustace SJ, et al. Multiple adults. Radiol Clin N Am. 2011;49(6):1197–217.
myeloma: a review of imaging features and radio- 55. Murphey MD, Carroll JF, Flemming DJ, et al. From
logical techniques. Bone Marrow Res. 2011; the archives of the AFIP: benign musculoskeletal lipo-
2011:583439. matous lesions. Radiographics. 2004;24(5):1433–66.
41. Ludwig H, Kumpan W, Sinzinger H. Radiography 56. Salam GA. Lipoma excision. Am Fam Physician.
and bone scintigraphy in multiple myeloma: a 2002;65(5):901–4.
comparative analysis. Br J Radiol. 1982;55(651): 57. Walker EA, Song AJ, Murphey MD. Magnetic
173–81. resonance imaging of soft-tissue masses. Semin
42. Woolfenden JM, Pitt MJ, Durie BG, et al. Comparison Roentgenol. 2010;45(4):277–97.
of bone scintigraphy and radiography in multiple 58. Walker EA, Petscavage JM, Brian PL, et al. Imaging
myeloma. Radiology. 1980;134(3):723–8. features of superficial and deep fibromatoses in the
43. Resnick D. Frequency and distribution of skeletal adult population. Sarcoma. 2012;2012:215810.
metastasis. Diagnosis of Bone and Joint Disorders. 59. El-Haddad M, El-Sebaie M, Ahmad R, et al.
4th ed. Philadelphia, PA: Saunders; 2002. Treatment of aggressive fibromatosis: the experience
44. Rubenstein J. Imaging of skeletal metastases. Tech of a single institution. Clin Oncol (R Coll Radiol).
Orthop. 2004;19(1):2–8. 2009;21(10):775–80.
45. Söderlund V. Radiological diagnosis of skeletal 60. Gounder MM, Lefkowitz RA, Keohan ML, et al.
metastases. Eur Radiol. 1996;6(5):587–95. Activity of Sorafenib against desmoid tumor/deep
46. Murphey MD, Robbin MR, McRae GA, et al. fibromatosis. Clin Cancer Res. 2011;17(12):4082–90.
The many faces of osteosarcoma. Radiographics. 61. Rockwood CAJ, Matsen FA III, Wirth MA, et al.
1997;17(5):1205–31. Tumors and related conditions. The shoulder. 4th ed.
47. Jaffe N, Bruland OS, Bielack S. Pediatric and adoles- Philadelphia, PA: Elsevier; 2009.
cent osteosarcoma. Boston, MA: Springer; 2010. 62. Walker EA, Salesky JS, Fenton ME, et al. Magnetic
48. Ritter J, Bielack SS. Osteosarcoma. Ann Oncol. resonance imaging of malignant soft tissue neoplasms
2010;21(Suppl 7):vii320–5. in the adult. Radiol Clin N Am. 2011;49(6):1219–34.
49. Murphey MD, Walker EA, Wilson AJ, et al. From 63. Petscavage-Thomas JM, Walker EA, Logie CI, et al.
the archives of the AFIP: imaging of primary chon- Soft-tissue myxomatous lesions: review of salient
drosarcoma: radiologic-pathologic correlation. imaging features with pathologic comparison.
Radiographics. 2003;23(5):1245–78. Radiographics. 2014;34(4):964–80.
50. Brenner W, Conrad EU, Eary JF. FDG PET imag- 64. Walker E, Brian P, Longo V, et al. Dilemmas in distin-
ing for grading and prediction of outcome in chon- guishing between tumor and the posttraumatic lesion
drosarcoma patients. Eur J Nucl Med Mol Imaging. with surgical or pathologic correlation. Clin Sports
2004;31(2):189–95. Med. 2013;32(3):559–76.
51. Murphey MD, Senchak LT, Mambalam PK, et al. 65. Smith SE, Murphey MD, Motamedi K, et al. From the
From the radiologic pathology archives: Ewing sar- archives of the AFIP. Radiologic spectrum of Paget
coma family of tumors: radiologic-pathologic correla- disease of bone and its complications with pathologic
tion. Radiographics. 2013;33(3):803–31. correlation. Radiographics. 2002;22(5):1191–216.
Imaging of Pediatric Disorders
of the Shoulder 13
Jorge Delgado and Diego Jaramillo
13.1 Introduction most of the longitudinal growth of this bone [1],

and the lateral clavicular physis, which is not
The skeletal development of the shoulder influ- always present, can often be confused with a
ences the imaging appearance of congenital, fracture [2].
infectious, and inflammatory diseases in chil- Throughout osseous maturation, multiple sec-
dren. Additionally, as competitive sports are ondary ossification centers arise from the carti-
being practiced at an earlier age and at a higher laginous epiphyses and apophyses of the
level, the number of pediatric patients requiring shoulder. Bone growth from secondary ossifica-
shoulder imaging is continuously increasing. tion centers occur by endochondral ossification
Understanding the normal development of the [3]. The appearance and growth of each second-
shoulder is essential to appropriately interpret ary ossification center occur at a different age,
imaging findings. which modifies the appearance of the shoulder at
different stages of development (Table 13.1).
13.2 Development of the Normal

Pediatric Shoulder 13.2.1 Anatomy
At birth, the diaphysis of the clavicle, the body 13.2.1.1 Proximal Humerus
and spine of the scapula, and the proximal The proximal humeral epiphysis has three ossifi-
humeral diaphysis are ossified, whereas the prox- cation centers: the head of the humerus, the
imal humeral epiphysis, the glenoid, the coracoid greater tuberosity, and the lesser tuberosity. At the
process, the acromion, the vertebral border and moment, there is debate about the lesser tuberos-
the inferior angle of the scapula, and the lateral ity secondary ossification center being an inde-
epiphysis of the clavicle are composed of hyaline pendent entity or being part of the humeral head
cartilage [1]. The medial clavicular physis, which ossification center [4]. Before the appearance of
closes at 22–25 years of age, is responsible for the ossification centers in the proximal humerus, a
progression of changes that begins with chondro-
cyte hypertrophy and is followed by central vas-
J. Delgado (*)
Department of Radiology, Harvard Medical School,
cularization leads to the formation of ill-defined,
Massachusetts General Hospital, Boston, MA, USA small, low-to-intermediate T1, high T2 signal
D. Jaramillo
intensity (SI) foci called preossification centers,
Department of Radiology, Columbia University which should not be mistaken for intraepiphyseal
Medical Center, New York, NY, USA abnormalities. After the formation of early o steoid

302 J. Delgado and D. Jaramillo
Table 13.1 Approximate age of appearance and fusion of the multiple ossification centers of the shoulder [1, 2, 6, 9]
Bone structure Ossification center Age of appearance Age of fusion
Proximal humerus Head of the humerus 1–6 months 3–5 years
Greater tuberosity 9–12 months
Lesser tuberosity 12–16 months
Scapula: glenoid Subcoracoid 8–10 years 14–17 years
Centers in the inferior two-thirds of the 14–15 years 17–18 years
glenoid
Scapula: coracoid Center of the coracoid process 3 months 15–17 years
process Base of the coracoid process 8–10 years
Scapula: acromion Acromial secondary ossification centers 14–16 years 18–25 years
Scapula Vertebral border 14–20 years 22 years
Inferior angle
matrix within the preossification centers, this foci mal humeral fracture or proximal humeral
become of intermediate SI in both T1- and epiphysiolysis (“little league shoulder”) [6].
T2-weighted images (WI) consistent with the nor-
mal appearance of hematopoietic bone marrow 13.2.1.2 Coracoid
[4]. These areas rapidly become fatty bone mar- The coracoid process usually has two ossification
row [3]. The ossification center at the head of the centers. These centers appear in the middle point
humerus is the first to appear approximately at in the first year, and at the base of the coracoid
1–6 months of age, followed by the greater tuber- process at 10 years of age. A third ossification
osity ossification center and the lesser tuberosity center located in the tip of the coracoid process is
ossification center at 9–12 and 12–16 months of an uncommon anatomical variant that may mimic
age, respectively. The presence of an ossification a fracture [2].
center in the head of the humerus can be expected
in up to 20% of full-term newborns. Eventually, 13.2.1.3 Acromion
all ossification centers within the humeral head At birth, the acromion is a cartilaginous replica
fuse together at 3–5 years of age, creating a single of the ossified adult acromion. With growth, ossi-
epiphyseal ossification center [5]. After fusion, fication occurs from the primary ossification cen-
the osseous margins of the proximal humeral ter, located posteriorly, toward the anterolateral
epiphysis may be irregular, with a fragmented border of the bone, and multiple distal secondary
appearance on coronal images and a posterior ossification centers ossifying the most anterolat-
notch on axial images [1]. As growth continues, eral segment of the cartilaginous acromion [6].
the surface of the structure becomes smoother, The age range for the appearance and fusion of
abutting the proximal humeral physis [1]. these ossification centers is quite broad, with
During the first 3 months of life, the proximal these processes expected to occur between 14–16
humeral physis is smooth and has a flat or slightly and 18–25 years of age, respectively. Failure of
arched shape. After this period it becomes pro- fusion of the distal acromial ossification centers
gressively angulated, with a tented contour that may be mistaken for an avulsion fracture [6]. The
can be seen in the lateral aspect of the proximal failure of fusion between any of the different
humerus (Fig. 13.1). The physeal closure begins ossification centers of the acromion has been
in its central portion at approximately 14 and described as the cause of os acromiale [7]. The
15 years of age, and ends with the fusion of its most common form of os acromiale consists of a
posterolateral aspect at approximately 16 and large triangular meso-acromion that is separated
17 years of age for boys and girls, respectively. from the rest of the acromion by an irregular car-
Asymmetric widening of the physis and irregu- tilaginous layer with bone marrow edema visual-
larity of the metaphyseal border suggest proxi- ized along the bone-to-bone interphase. Recently,
13 Imaging of Pediatric Disorders of the Shoulder 303
a b
Fig. 13.1 Normal change in the angulation of the proxi- history of shoulder injury. The proximal humeral physis
mal humeral physis. (a) Coronal T1-WI in a newborn boy has a tented contour (arrowhead) with the most superior
with a history of distal humeral fracture. The proximal angle located in the midsection of the physis. Additionally,
humeral physis has a smooth and slightly arched shape residual hematopoietic bone marrow is seen as a rim of
(arrowhead), which is normal for this age group. No ossi- low SI in the medial border of the epiphysis (arrow) and as
fication center in the proximal humeral epiphysis is visu- low SI vertical stripes (asterisk) in the proximal
alized. (b) Coronal T1-WI in a 12-year-old girl with a humeral metaphysis
os acromiale has been described as a sequela of scapula at 14–17 years of age. A zone of cartilage
acromial apophysiolysis [8]. Os acromiale is usu- located between the primary coracoid center and
ally asymptomatic, but may be related to impinge- the primary scapular center acts as a bipolar phy-
ment, instability, and pain that may require sis with growth toward the body of the scapula
surgical treatment [6, 8]. (posterolateral) and the distal end of the coracoid
(anteromedial). There is normally a tongue of
13.2.1.4 Glenoid Fossa ossification within the cartilage. In the absence of
At birth, the subchondral bone of the glenoid has bone marrow edema, this normal ossification pat-
a convex appearance on plain radiographs; none- tern should not be confused with a superior gle-
theless, MR images show that newborns have a noid avulsion fracture [9] (Fig. 13.2). The
cartilaginous glenoid fossa with a similar contour multiple ossification centers located in the infe-
to the concave adult glenoid [1]. As growth rior two-thirds of the glenoid begin to form at
occurs, the subchondral bone of the glenoid 14–15 years of age and fuse by 17–18 years of
becomes flattened. At this stage, the osseous sur- age [9]. It is important not to mistake the inferior
face can have multiple undulations that may glenoid ossification centers with traumatic
mimic osteochondral injuries [1, 6]. The concave lesions [9]. Another common finding in the gle-
osseous glenoid fossa develops in its superior noid articular surface consists of a well-
third from the subcoracoid (or infracoracoid) circumscribed small focus of T2 hyperintensity
ossification center, whereas the inferior two- at its center called “bare spot of the glenoid” [9,
thirds develop from multiple ossification centers 10]. This is most likely an acquired finding that
around the glenoid rim that coalesce to form a may be related to shoulder instability and should
horseshoe-like ossification center. The subcora- not be interpreted as osteochondritis dissecans
coid ossification center is the first to appear at (ODC) or glenolabral articular cartilage disrup-
approximately 8–10 years of age, fusing with the tion (GLAD) (Fig. 13.3) [9–11].
a b
Fig. 13.2 Subcoracoid ossification center in a 10-year- superior aspect of the glenoid (arrows). In the absence of
old boy with a history of shoulder trauma. (a) Coronal edema, this finding should not be confused with a superior
T1-WI and (b) coronal T2-WI of the right shoulder show- glenoid avulsion fracture
ing a small tongue of ossification located in the anterior-
a b
Fig. 13.3 Differences in the appearance of a bare spot of Coronal gadolinium-enhanced fat-suppressed T1-WI of
the glenoid (a) and an OCD of the glenoid (b). (a) Coronal the shoulder in an 11-year-old girl during workout for a
T2-WI of the shoulder in a 13-year-old girl with a history focal bony lesion previously seen on plain films. Intense
of shoulder dislocation. A regular, well-defined, bare spot enhancement of an irregular lesion located in the central
located in close proximity to the isocenter of the glenoid sublabral region of the glenoid consistent with the
without adjacent bone marrow edema is seen (arrow). (b) appearance of an OCD of the glenoid is seen (arrow)
13.2.1.5 ertebral Border and Inferior

V can be found in the proximal humeral metaphy-
Angle of the Scapula sis as vertically oriented stripes with well-delim-
Two ossification centers are apparent in the verte- ited margins, in the humeral head as a halo of
bral border and the inferior angle of the scapula. low T1, high T2 SI in the medial border of the
Both appear at puberty and fuse with the scapula epiphysis, and in the distal clavicle and distal
approximately at 22 years of age [2]. acromion until late adolescence and early adult-
hood [1, 6, 12] (Fig. 13.2).
13.2.1.6 Bone Marrow
Transformation 13.2.1.7 Metaphyseal Stripes
Transformation from hematopoietic bone mar- The most inner layer of the periosteum called the
row (red marrow) to fatty bone marrow (yellow cambium of the periosteum or metaphyseal stripe
marrow) occurs in a predictable and organized is a highly vascularized tissue that is responsible
fashion [3]. At birth, the bone marrow through- for the appositional growth of long bones. It is
out the body is hematopoietic and, accordingly, seen on MR imaging as a 1–2 mm symmetric rim
has a low SI on T1-WI and a high SI of fat-sup- of intermediate SI on T1-WI and high SI of fluid-
pressed fluid-sensitive sequences. In the upper sensitive sequences that surrounds the low-SI
extremities, bone marrow transformation begins bone cortex and is in direct contact with the low-
distally and continues proximally (from the fin- SI periosteum (Fig. 13.5). This layer is seen in
gers to the shoulder) [3]. In the humerus, marrow the proximal humeral metaphysis, and less com-
conversion occurs first in the epiphyses, fol- monly in the distal clavicular metaphysis and
lowed by central diaphysis, and then continues acromion in patients aged 5 months to 14 years.
proximally and distally until complete conver- After this age, it slowly disappears, being almost
sion of the metaphyseal marrow results always imperceptible by the age of physeal clo-
(Fig. 13.4). Residual hematopoietic bone m arrow sure [4, 6, 13]. This normal finding on MR
a b
Fig. 13.4 Bone marrow transformation. Sagittal T1-WI ossification center (arrow) and the humeral mid-diaphysis
of the shoulder in (a) a 4-month-old girl, and (b) a have high SI on T1-WI consistent with the normal appear-
15-month-old girl. (a) The humeral head ossification cen- ance of fatty bone marrow. The proximal humeral metaph-
ter (arrow) and the proximal humeral metaphysis (arrow- ysis (arrowhead) still has SI characteristics of
head) at 4 months of age have a low SI on T1-WI hematopoietic bone marrow. The imaging findings seen
consistent with the normal appearance of hematopoietic correspond to the predictable and organized trans-
bone marrow. (b) At 15 months of age the humeral head formation of bone marrow during the childhood
spontaneous recovery is about 65%. Rarely,

injury of the nerve roots C5, C6, C7, C8, and T1
occurs. With this pattern of injury spontaneous
recovery occurs in approximately 50% of cases
if the Horner triad is not seen, whereas it almost
never occurs when the Horner triad is present
[17, 18].
Although surgical exploration is recognized as
the reference standard for determination of nerve
injuries, studies have shown the feasibility of
demonstrating intraductal nerve root injures with
CT myelography [19] and, more recently, with
high-resolution MR imaging, by obtaining heav-
ily T2-WI using steady-state free precession
sequences [14].
Up to one-third of affected children will have
Fig. 13.5 Sagittal T2-WI of the right shoulder in a
some residual dysfunction, most commonly
10-year-old girl with concern for internal derangement weakness in the shoulder external rotators (teres
following trauma. A high-SI line in between the low SI minor and infraspinatus), shoulder abductors,
bone cortex and the low-SI periosteum consistent with a and shoulder forward elevators. As a result, there
metaphyseal stripe (arrow) is visualized
is a contracture of the subscapularis and pectora-
lis major muscles, and capsuloligamentous con-
imaging should not be confused with periosteal tracture of the shoulder may lead to cartilaginous
reaction seen in pathologic processes such as and bone deformities. The formation of a hypo-
osteomyelitis, fracture, or tumors [4]. plastic humeral head and posterior humeral head
displacement ultimately leads to subluxation,
dislocation, or a fixed articular deformity [20].
13.3 Diseases Plain radiographs are inadequate to evaluate
the extent of bone deformity, as ossification of
13.3.1 Congenital Diseases the humeral head is delayed until puberty [1]. In
children younger than 1 year of age, ultrasonog-
13.3.1.1 Brachial Plexus Palsy raphy has demonstrated to be a useful modality
Neonatal brachial plexus palsy results from the for the detection of posterior subluxation of the
traction of the brachial plexus during birth, humeral head. A posterior approach, obtaining
when the neonate shoulder becomes locked by images in the axial plane from the posterior
the pubic symphysis of the mother and opposite aspect of the shoulder to demonstrate the
traction is performed by the labor attendant [14, humeral head ossification centers and the poste-
15]. The prevalence of this complication has rior aspect of the scapula, results in more repro-
been reported as 1–3 cases per 1000 live births ducible and interpretable images in comparison
[15, 16]. Risk factors include shoulder dystocia, to images obtained in the axial plane from the
exceptionally large baby (>4.5 Kg), and forceps lateral aspect of the shoulder. Additionally, the
or vacuum extraction [15]. The most common posterior approach is less affected by the ossifi-
pattern of injury, seen in 80% of the cases, cation of the humeral head. With the posterior
involves injury of the vertebral roots at levels approach, shoulder posterior subluxation or dis-
C5 and C6 [14]. These cases have a good prog- location is seen as a posteriorly located center of
nosis with spontaneous recovery in approxi- the humeral head ossification center in relation
mately 90% of patients. When injury of the to the posterior scapular line, whereas in the
nerve roots C5, C6, and C7 occurs, the rate of normal shoulder the center of the humeral head
a b
c d
Fig. 13.6 Comparison of the right (a and c) and left (b posterior scapular line (dashed arrow) consistent with
and d) shoulders in a girl with brachial plexus palsy of the posterior subluxation of the left shoulder. At 2 years of
left shoulder. At 10 months of age US imaging of the right age, GRE MR imaging shows a (d) dysplastic left humeral
shoulder shows (a) the humeral head ossification center head with posterior sloping, posterior subluxation, and a
(arrow) in normal relation to the posterior scapular line poorly defined acetabular labrum in comparison to a (c)
(dashed arrow). (b) Note the posterior location of the normal right humeral head and labrum
humeral head ossification center (arrow) in relation to the
ossification is located anterior with respect to the ular angle, described as the angle obtained
same line [21] (Fig. 13.6). between a line located from the anterior and pos-
In children from 1 to 5 years of age, MR terior margins of the cartilaginous glenoid fossa
imaging of the affected shoulder with compara- and a second line from the central point of the
tive imaging of the contralateral shoulder is the glenoid fossa to the medial tip of the scapula,
best imaging approach. The protocol should can be measured to determine the degree of gle-
include bilateral shoulder imaging using high- noid version [23]. Retroversion of the humeral
resolution, 3 mm thick, axial and oblique coro- head leads to thinning of the posterior aspect of
nal GRE sequences to evaluate the glenoid the glenoid, and in more severe cases thinning of
version angle, the shape of the humeral head, the the superior aspect of the glenoid cartilage, pos-
degree of glenoid hypoplasia, and the incongru- terior displacement of the posterior labrum and
ity of the glenohumeral joint [22]. In children humeral head, and subsequent subluxation or
younger than 5 years, high SI on GRE imaging dislocation. Muscle atrophy and intramuscular
in the physis and the cartilaginous glenoid and fatty replacement may be evident in the subscap-
low SI in the labrum are seen [1]. The glenoscap- ularis muscle and to a lesser extent in the
infraspinatus and supraspinatus muscles. insertional zone are more common than full-
Changes observed in the subscapularis muscle thickness supraspinatus tears located in the criti-
are of paramount importance as they have been cal zone [27].
related to a greater degree of glenoscapular
deformity [23, 24]. 13.3.2.1 Fractures
In all patients with brachial plexus palsy, reha- The most common fracture of the shoulder
bilitation therapy should be the center of inter- involves the clavicle, usually in the midshaft,
vention with the aim of avoiding contracture caused by direct trauma or fall with an extended
formation, improving muscle strength, and pre- upper extremity [25]. A thick periosteal layer
venting compensatory movement patterns [17]. acts as a barrier for the displacement of the frac-
In older children, surgery is restricted to capsular tured bone segments, especially in children
release, extra-articular tendon transfers and gle- younger than 10 years of age. Although most
noid osteotomy to restore external rotation, or cases can be treated conservatively, there is
salvage procedures such as humeral external der- increasing controversy in the indications for
otational osteotomy for the correction of operative management [28]. Almost all cases of
advanced glenohumeral deformity [25]. clavicular fractures can be evaluated using con-
ventional radiographs and additional imaging is
almost never required.
13.3.2 Trauma and Sport-Related Less commonly, fractures of the proximal
Injuries humerus and scapula can be observed. In chil-
dren under 10 years of age, with extensive remod-
Most pediatric osseous injuries occur at the eling capabilities, nonoperative treatment is
chondro- osseous junctions of the physes and usually the recommended option. Beyond
apophyses, especially during the growth spurt in 13 years of age, remodeling capabilities are simi-
adolescence, due to physeal thickening and lar to the adult, and more aggressive surgical
abrupt increase in muscle strength. More than treatment is recommended. Patients between 10
half of all high school students participate in and 13 years should be evaluated in a case-by-
competitive sports in the United States, and there case basis. In neonates and infants, complete
has been a significant increase in the number and separation of the proximal humeral epiphysis fol-
severity of shoulder injuries among this age lowing obstetric, accidental, or non-accidental
group [26]. The risk of an acute shoulder injury trauma can be seen. Due to the absence of ossifi-
while participating in sports is estimated to be 2 cation centers in the proximal humeral epiphysis
per 10,000 athlete exposures, being substantially up to 6 months following birth, sonography of the
higher in boys, during competition in compari- shoulder is the best diagnostic modality. It can be
son to practice, and in contact sports including performed on the patient bedside without the
football and wrestling [26]. Chronic sport- need of sedation, and images are usually superior
related shoulder injuries are more commonly to MR imaging (Fig. 13.7) [29].
seen in baseball and tennis [1]. In contrast to Physeal fractures of the shoulder are uncommon,
adults, in whom full-thickness rotator cuff tears, comprising about 3% of all physeal fractures. Due
biceps pathology, and osteoarthritis account for to the transformation of the proximal humeral phy-
most disease, in children and adolescents, labral sis from a flat structure in infants to a tented contour
disease involving primarily the anterior labrum in adolescents, Salter-Harris Type I fractures are
and the superior labrum (superior labrum ante- more common in younger children, whereas Salter-
rior posterior lesions (SLAP)) are responsible Harris Type II fractures occur more frequent in
for about four of every five injuries seen by older children and adolescents. The prognosis of
shoulder arthroscopy. In adolescents, partial physeal fractures in this location is excellent and
supraspinatus tendon avulsions located in the surgical treatment is almost never required [30].
a b
Fig. 13.7 Anterior US imaging of the (a) right and (b) humeral head (arrow) on top of a well-demarcated left
left proximal humeri in a 3-day-old girl with a history of humeral diaphysis. This finding is similar to a scoop of ice
left-shoulder dislocation following shoulder dystocia. (a) cream slipping off the top of a cone. (c) MR imaging of
The right proximal non-ossified humeral head (arrow) is the same patient performed 1 day after the US images
well positioned following the contour of the ossified showing a posterolateral subluxation of the humeral head
humeral diaphysis. (b) Absence of the left proximal (arrow)
13.3.2.2 Dislocations 13.3.2.3 Little Leaguer’s Shoulder

Children with anterior shoulder dislocation fol- Repetitive microtrauma sustained by adolescent
lowing low-energy trauma have a much lower athletes involved in repetitive overhead throwing
incidence of proximal humeral fractures in com- may result in disruption of endochondral ossifi-
parison to adults, and thus do not require prereduc- cation and an increase in the number of chondro-
tion radiographs [31]. Postreduction radiographs cytes remaining in the metaphysis seen as physeal
are still recommended. thickening and irregularity [32]. The clinical pre-
The pathophysiology and imaging findings of sentation is characterized by chronic pain in the
anterior dislocations of the shoulder are the same lateral aspect of the shoulder and tenderness to
for older children than for adults and thus will not palpation. Radiographs and MR imaging are
be discussed. characteristic for physeal widening and irregularity.
a b
Fig. 13.8 (a) AP radiograph and (b) coronal PD image of which should not be confused with an avulsion fracture. (b)
the right shoulder in a 13-year-old boy who is a baseball On MR images, physeal widening and irregularity are also
pitcher. (a) Physeal widening and irregularity in the lateral seen; additionally, bone marrow edema and effacement of
proximal humeral physis are visualized (arrow). Note the the zone of provisional calcification are visualized (arrow).
well-corticated acromial ossification center (arrowhead), Findings are consistent with a little leaguer’s shoulder
On MR imaging increased metaphyseal SI on 13.3.3 Infectious Diseases

water-sensitive sequences and effacement of the
zone of provisional calcification in all sequences 13.3.3.1 Acute Osteomyelitis
is also visualized (Fig. 13.8). The treatment of The humerus is the site of involvement in 13% of
this disease consists of cessation of sport activi- pediatric hematogenous osteomyelitis cases. It
ties to avoid the formation of bony bridges [33]. may be seen rarely (<1% of total cases), in the
clavicle or the scapula [34]. The metaphyses of
13.3.2.4 Acromial Apophysiolysis long bones are more vascularized in the pediatric
Acromial apophysiolysis is a disease that can population in comparison to adults, making them
occasionally be seen on baseball or softball pitch- more susceptible to infection by hematogenous
ers in their late adolescence, especially males who spreading, usually following subclinical bactere-
have a pitch count higher than 100 pitches per mia. Microtrauma or emboli may occlude these
week. On MR images, it is characterized by slow-flowing vessels creating a nidus for
incomplete fusion and bone marrow edema on the infection.
meta-acromial and meso-acromial ossification Just like in other bones of the growing skele-
centers (Fig. 13.9). It presents clinically as pain ton, infections are more commonly due to
and tenderness to palpation at the superior shoul- Staphylococcus aureus, Streptococcus pyogenes,
der. Patients who present at some point of their and Streptococcus pneumoniae. Due to the
lives with acromial apophysiolysis are at increased improvement in culture techniques, Kingella
risk of having full-thickness rotator cuff tears and kingae, a gram-negative organism, is now recog-
meta-acromion-meso-acromion-type os acro- nized as a significant causative agent of osteomy-
miale. The association between this type of stress elitis in children younger than 4 years of age.
injury and the presence of os acromiale suggest Although less commonly, fungi and parasites can
that the latter may not be an anatomical variant, also be the causative organisms for osteomyelitis
but a sequela of repetitive apophyseal injury [8]. in children [35].
Fig. 13.9 Acromial apophysiolysis.

Axial PD MR image of the right shoulder
in a 15-year-old girl who is a softball
pitcher. Incomplete fusion of the
meso-acromion and meta-acromion, bone
marrow edema (arrow), and cystic
changes (dashed arrow) are visualized
The clinical presentation consists of fever, is common to see subperiosteal collections ele-
pseudoparalysis of the arm, and pain with passive vating the periosteum and stopping at the peri-
motion. Imaging should focus on detecting the chondrial junction (Fig. 13.11). MR imaging is
presence of infection, excluding additional foci also valuable to detect complications of osteomy-
of osteomyelitis, and detecting drainable collec- elitis such as chronic osteomyelitis and bony
tions. Radiographs should be the first step in the bridging across the physis [1].
workout for osteomyelitis. Nevertheless, findings
suggestive of osseous infection will be seen in 13.3.3.2 Septic Arthritis
less than 20% of patients; thus, its use must be The shoulder accounts for 5% of all septic arthri-
focused on excluding differential diagnoses such tis in children [36]. Most cases occur in boys
as trauma or tumors [34]. MR imaging is the best under the age of 2 years, particularly in neonates
modality to depict acute osteomyelitis. The pro- in the intensive care unit [37]. Similarly to osteo-
tocol should include T1-weighted sequences, fat- myelitis, most cases in the pediatric population
suppressed water-sensitive sequences, and are caused by hematogenous spreading or by
gadolinium-enhanced sequences. The infected direct extension into the joint space from infec-
area appears as having a low SI on T1-WI, a high tions located in the soft tissues or adjacent
SI on water-sensitive sequences, and an increased metaphyses. The latter is a specific phenomenon
heterogeneous bone marrow enhancement on seen more commonly in children under the age of
postcontrast imaging. Postcontrast imaging is of 18 months [38].
special value in the evaluation of suspected osteo- The most common causative organisms of
myelitis in the non-ossified epiphyseal cartilage septic arthritis are the same as for osteomyelitis.
(Fig. 13.10). It is important to differentiate the Neisseria gonorrhoeae can be found in neonates
normal appearance of hematopoietic bone mar- and sexually active adolescents, and type B
row in the growing skeleton from the findings Haemophilus influenzae may be occasionally
seen on osteomyelitis. The SI of normal hemato- cultivated in unvaccinated children.
poietic marrow on T1-WI is never lower than the In 85% of cases, the symptoms are monoarticu-
SI of the adjacent musculature [3]. In children, it lar and the presence of multiple joint involvement
a b
Fig. 13.10 Coronal MR imaging of the left shoulder in a enhanced fat-suppressed T1-WI showing rim enhance-
2-month-old boy with osteomyelitis. (a) T1-WI shows ment of the fluid collection located in the proximal
homogeneous low SI in the proximal humeral epiphysis metaphysis (arrowhead) and a focus of enhancement in
and metaphysis. The high content of hematopoietic bone the non-ossified proximal humeral epiphysis (arrow).
marrow in young infants makes the diagnosis of osteomy- These findings are consistent with osteomyelitis extension
elitis especially difficult. (b) T2-WI showing a fluid col- from the metaphysis into the proximal epiphysis thru the
lection in the proximal metaphysis (arrow). No apparent nutrient metaphyseal capillaries
extension into the epiphysis is visualized. (c) Gadolinium-
a b
Fig. 13.11 Coronal MR imaging of the right humerus in sponds to the area of bone marrow edema seen on the (b)
a 3-year-old boy with a history of 8 days of fever and T2-WI; additionally, a large subperiosteal collection
1 day of pain and pseudoparalysis of the right arm. (a) (arrow) and extensive myositis (dashed arrow) involving
T1-WI shows decreased bone marrow SI which corre- the deltoid muscle are visualized
must raise doubts on the infectious etiology of the not developed, septic arthritis results in a delayed
case [39]. Radiographs add little to the diagnosis appearance of small and irregular secondary ossi-
but should be ordered to exclude trauma as the fication centers with final deformity of the humeral
cause for the patient’s symptoms. US is useful to head. In cases in which delayed or inappropriate
detect joint fluid and to guide joint aspiration, but treatment is performed, proximal humeral physis
does not help to differentiate infected from nonin- involvement may occur. As 80% of the humeral
fected fluid [40]. MRI is the imaging method of length depends on the proximal physis, this may
choice for this disease. Findings include effusion, cause significant shortening of the extremity [41].
reactive edema within the adjacent bone, and
synovial enhancement of gadolinium-enhanced
images. The use of postcontrast subtraction imag- 13.3.4 Inflammatory Diseases
ing may be of great use to depict subtle changes in
the blood flow of the epiphyses and synovium [1]. 13.3.4.1 Juvenile Idiopathic Arthritis
In any case of suspected septic arthritis, joint aspi- The shoulder is affected late in the course of the
ration with cytology and microbiology is the cor- disease, and involvement occurs more often in
nerstone of diagnosis [40]. subjects with polyarticular disease or enthesitis-
The sequelae depend on the age of presenta- related arthritis (positive HLA-B27) [42, 43]. At
tion, virulence of the infecting pathogen, and the onset, about 5% of patients present with
appropriate treatment onset. In children under shoulder involvement, whereas after 5 years of
12 months of age, in whom secondary ossification having JIA approximately 21% of subjects will
centers of the proximal humeral epiphysis have have shoulder involvement [42].
US and MRI are superior to clinical examina- to differentiate a fibrotic synovium from a highly
tion in the detection of joint inflammation and vascularized inflammatory hypertrophic
should be considered in the diagnosis and fol- synovium, or from a joint effusion, and thus
low-up of JIA. Both techniques are also superior contrast-enhanced imaging is recommended.
to radiographs for the evaluation of structural Postcontrast imaging should be performed
abnormalities such as erosions, joint-space within 5 min after the administration of gado-
narrowing, and deformity [44]. US is also help- linium to avoid the diffusion of contrast media
ful to detect enthesitis-related arthritis, espe- from the synovium into the joint space, creating
cially at the insertions of the quadriceps, the the illusion of a thickened synovium and gradual
common extensor, and the Achilles tendon [45]. enhancement of the joint fluid [1, 43, 47].
MRI is the best imaging modality to evaluate
JIA. It detects disease extent and progression 13.3.4.2 hronic Recurrent Multifocal
C
and evaluates response to treatment. Fat- Osteomyelitis
suppressed PD and gradient-echo sequences can Chronic recurrent multifocal osteomyelitis
best evaluate glenohumeral cartilage abnormali- (CRMO) is an idiopathic inflammatory noninfec-
ties. Hypertrophic synovium may appear as a tious disease affecting multiple bones of the skel-
thickened and irregular structure with low SI eton, showing acute, subacute, and chronic
on T1-WI and high SI on fat-suppressed patterns of inflammation in the affected areas. It
T2-WI. Other important imaging findings occurs mostly in the late childhood and early
include erosions and deep cartilage loss extend- adolescence with an incidence peak between 7
ing into the subchondral bone that may cause and 12 years of age. Girls are affected twice more
internal joint derangement and rice bodies which often than boys [48, 49]. For staging, whole-body
are small aggregates of mononuclear cells and MR imaging is replacing scintigraphy as the
fibrin seen in the synovial fluid or bursae method of choice to depict clinically occult sites
suggestive of severe synovial inflammation
of disease. Whole-body MR imaging is done by
(Fig. 13.12) [46]. In some cases it is impossible using STIR sequences that may show evidence of
a b
Fig. 13.12 MR arthrogram of the right shoulder in a injection of gadolinium are seen (arrows). These bodies
17-year-old girl with a history of persistent shoulder pain. are aggregates of mononuclear cells and fibrin secondary
(a, b) A significant number or low-T1-SI bodies within to severe synovial inflammation usually seen in JIA
the distended articular space following intra-articular
foci of high SI, which must be confirmed by 13.3.5 Benign Tumors

seeing low SI in these same areas on

T1-WI. Although most of the literature describes 13.3.5.1 Simple Bone Cysts
lesions seen in CRMO as symmetric, there is Simple bone cysts, also known as unicameral
usually lack of temporal symmetry, making bone cysts or solitary bone cysts, are uncom-
lesions to appear at different stages and being mon lesions that represent 3% of all primary
even inexistent on imaging. During the active bone tumors. The peak of incidence occurs
phase diffuse inflammation, small joint effusions, between 9 and 15 years of age [54]. About 50%
and periosteal inflammation may be seen; never- of these lesions occur in the proximal humeral
theless, the presence of large fluid collections, metaphysis. On radiographs, these tumors are
sequestrum, or a sinus tract makes the diagnosis characterized as cystic lesions in the central
of CRMO less likely, favoring a bacterial etiol- area of the metaphysis without periosteal reac-
ogy [1]. Later in the course of the disease, radio- tion [55]. A fallen fragment may be seen fol-
graphs may reveal osteolytic lesions with a lowing pathologic fractures [56]. These tumors
sclerotic border [50]. Usually the metaphyses and are usually described as being painless; how-
metaphyseal equivalents are the most common ever, they are commonly associated with patho-
locations, but involvement of the clavicle is fairly logic fractures. On MR imaging its SI is
common accounting for up to 30% of CRMO described as intermediate on T1-WI and high
lesions (Fig. 13.13) [51]. Lesions in the clavicle on T2-WI. Noncomplicated fluid-filled cysts
usually manifest with local pain and swelling are often visualized; however, following patho-
located in the medial third of the bone. logic fractures, fluid-fluid levels may appear.
Additionally, lytic lesions and onionskin-like On gadolinium-enhanced imaging, nodular and
periosteal reaction, which can be better evaluated thick perilesional enhancement is usually
on CT imaging, are apparent. The cycle of heal- visualized.
ing-relapse leads to progressive hyperostosis and
sclerosis of the medial aspect of the clavicle 13.3.5.2 Chondroblastoma
without involvement of the sternoclavicular joint. Chondroblastomas are uncommon cartilaginous
Rarely the scapula may be affected [52]. In the benign tumors that account for about 2% of all
humerus, patients are at greatest risk for the for- primary bone tumors, but about 20% of them
mation of bony- bridging leading to growth occur in the proximal humerus [57]. They present
disturbance [53]. twice more commonly in boys compared to girls
a b
Fig. 13.13 Clavicular CRMO in a 9-year-old female. area of high SI within the bone marrow on T2-WI (b)
Coronal T1-WI (a) of the chest showing low-SI bone mar- (arrow). There is adjacent soft-tissue edema, but large
row in the right clavicle (arrow) which corresponds to an fluid collections, sequestrum, and sinus tracts are absent
with a peak incidence in the adolescence and border, is seen in almost all lesions. Fluid-fluid
early adulthood [32, 58]. Chondroblastomas levels may be seen in 20–30% of patients [32]
originate from the secondary ossification centers (Fig. 13.14).
of the epiphyses and apophyses, with the most
common affected bones being the proximal tibial
epiphysis and the proximal humeral epiphysis. 13.3.6 Malignant Tumors
The clinical presentation includes severe pain,
limitation in the range of motion of the adjacent Osteosarcoma and Ewing sarcoma are the most
joint, local tenderness, and swelling. On plain common bone malignancies in the childhood,
radiographs, these lesions have a lytic appear- accounting for 6% of all malignancies in this age
ance with well-defined sclerotic margins. group [56]. The proximal humeral metaphysis is
Calcification may be seen in up to 60% of cases the third most common location for osteosar-
[55]. On MR imaging these tumors are seen as an coma, which occurs twice more commonly in
intraosseous lobulated mass with low-to- boys compared to girls. Ewing sarcoma usually
intermediate SI on T1-WI and intermediate-to- occurs in the pelvis followed by the metaphyses
high SI on water-sensitive sequences surrounded of the femur, tibia, and humerus in respective
by a halo of bone marrow edema. A thin low T1, order, and boys are equally affected as girls [56,
low T2 SI rim that corresponds to the sclerotic 59]. Children with either tumor can have deep
a b
Fig. 13.14 Chondroblastoma in a 15-year-old girl with a shows low-to-intermediate-SI mass surrounded by a low-
history of crepitus and pain in the right shoulder. (a) AP SI rim of sclerosis (arrow). (c) Coronal STIR image shows
radiographs show a well-demarcated lytic lesion with a high-SI lesion surrounded by a low-SI rim and diffuse
sclerotic borders in the proximal humeral metaphysis bone marrow edema (arrow)
(arrow). No periosteal reaction is seen. (b) Sagittal T1-WI
c pain lasting for several months, which is increased

with activity or motion of the adjacent joint [59].
Additionally, for Ewing sarcoma systemic symp-
toms can include fever, anemia, leukocytosis, and
elevated erythrocyte sedimentation rate. The goal
of imaging is to define the extent of the primary
lesion in relation to adjacent joints, bones, blood
vessels, and nerves, and the presence of metasta-
ses. Initial imaging usually consists of conven-
tional radiographs, which are used to determine
the aggressiveness of the tumor and suggest
malignancy. It is useful to perform longitudinal
imaging primarily on the sagittal plane in order to
avoid phase-encoding artifacts from the thoracic
structures. On MR imaging, osteosarcomas and
Ewing sarcoma are seen as having low SI on
T1-WI and high SI on water-sensitive sequences.
The infiltrated bone has low SI in all sequences
and in T1-WI the SI is lower than the one of the
surrounding muscles (Fig. 13.15). In both tumors,
extensive bone marrow edema and soft-tissue
edema are seen [56]. Following gadolinium
injection, avid heterogeneous enhancement is
Fig. 13.14 (continued) present for both tumors [56].
Fig. 13.15 Osteosarcoma in a 13-year-old

boy. (a) AP radiographs of the left shoulder
a
show poor defined borders of the lesion and
aggressive speculated periosteal reaction
(arrows) with the presence of Codman
triangles (arrowheads). (b) Sagittal T1-WI
shows infiltrated, low-SI bone marrow in the
proximal humeral metaphysis (asterisk). Note
that the SI of the bone marrow is lower than
the one seen on the adjacent muscles;
additionally, a significant soft-tissue
component with disruption of the normal
anatomy and diffuse disruption of the bone
cortex is visualized (arrow). (c) Sagittal
gadolinium-enhanced fat-suppressed T1-WI
shows intense heterogeneous enhancement of
the soft-tissue component (arrow)
b c
plexus birth palsy: a magnetic resonance imaging

References study. J Pediatr Orthop. 2010;30(1):60–6.
6. Zember JS, Rosenberg ZS, Kwong S, Kothary SP,
1. Chauvin NA, Jaimes C, Laor T, Jaramillo D. Magnetic Bedoya MA. Normal skeletal maturation and imag-
resonance imaging of the pediatric shoulder. Magn ing pitfalls in the pediatric shoulder. Radiographics.
Reson Imaging Clin N Am. 2012;20(2):327–47.. xi 2015;35(4):1108–22.
2. Rockwood CA. The shoulder. Philadelphia, PA: 7. Johnston PS, Paxton ES, Gordon V, Kraeutler MJ,
Saunders/Elsevier; 2009.. http://hdl.library.upenn. Abboud JA, Williams GR. Os acromiale: a review and
edu/1017.12/1337257 Connect to full text an introduction of a new surgical technique for man-
3. Laor T, Jaramillo D. MR imaging insights into agement. Orthop Clin North Am. 2013;44(4):635–44.
skeletal maturation: what is normal? Radiology. 8. Roedl JB, Morrison WB, Ciccotti MG, Zoga
2009;250(1):28–38. AC. Acromial apophysiolysis: superior shoulder pain
4. Kwong S, Kothary S, Poncinelli LL. Skeletal devel- and acromial nonfusion in the young throwing athlete.
opment of the proximal humerus in the pediatric Radiology. 2015;274(1):201–9.
population: MRI features. AJR Am J Roentgenol. 9. Kothary S, Rosenberg ZS, Poncinelli LL, Kwong
2014;202(2):418–25. S. Skeletal development of the glenoid and glenoid-
5. Clarke SE, Chafetz RS, Kozin SH. Ossification of the coracoid interface in the pediatric population: MRI
proximal humerus in children with residual brachial features. Skelet Radiol. 2014;43(9):1281–8.
10. Kim HK, Emery KH, Salisbury SR. Bare spot of the athletes, 2005/2006-2011/2012. Pediatrics.
glenoid fossa in children: incidence and MRI features. 2014;133(2):272–9.
Pediatr Radiol. 2010;40(7):1190–6. 27. Zbojniewicz AM, Maeder ME, Emery KH, Salisbury
11. Ly JQ, Bui-Mansfield LT, Kline MJ, DeBerardino SR. Rotator cuff tears in children and adolescents:
TM, Taylor DC. Bare area of the glenoid: magnetic experience at a large pediatric hospital. Pediatr
resonance appearance with arthroscopic correlation. J Radiol. 2014;44(6):729–37.
Comput Assist Tomogr. 2004;28(2):229–32. 28. Caird MS. Clavicle shaft fractures: are children
12. Zawin JK, Jaramillo D. Conversion of bone marrow in little adults? J Pediatr Orthop. 2012;32(Suppl 1):
the humerus, sternum, and clavicle: changes with age S1–4.
on MR images. Radiology. 1993;188(1):159–64. 29. Goldfisher R, Amodio J. Separation of the proxi-
13. Bedoya MA, Jaimes C, Khrichenko D, Delgado J, mal humeral epiphysis in the newborn: rapid diag-
Dardzinski BJ, Jaramillo D. Dynamic gadolinium- nosis with ultrasonography. Case Rep Pediatr.
enhanced MRI of the proximal femur: preliminary 2015;2015:825413.
experience in healthy children. AJR Am J Roentgenol. 30. Pahlavan S, Baldwin KD, Pandya NK, Namdari S,
2014;203(4):W440–6. Hosalkar H. Proximal humerus fractures in the pedi-
14. Somashekar D, Yang LJ, Ibrahim M, Parmar atric population: a systematic review. J Child Orthop.
HA. High-resolution MRI evaluation of neonatal 2011;5(3):187–94.
brachial plexus palsy: a promising alternative to tra- 31. Reid S, Liu M, Ortega H. Anterior shoulder dislo-
ditional CT myelography. AJNR Am J Neuroradiol. cations in pediatric patients: are routine prereduc-
2014;35(6):1209–13. tion radiographs necessary? Pediatr Emerg Care.
15. Foad SL, Mehlman CT, Ying J. The epidemiology of 2013;29(1):39–42.
neonatal brachial plexus palsy in the United States. J 32. Jaimes C, Chauvin NA, Delgado J, Jaramillo D. MR
Bone Joint Surg Am. 2008;90(6):1258–64. imaging of normal epiphyseal development and
16. Pondaag W, Malessy MJ, van Dijk JG, Thomeer common epiphyseal disorders. Radiographics.
RT. Natural history of obstetric brachial plexus 2014;34(2):449–71.
palsy: a systematic review. Dev Med Child Neurol. 33. Obembe OO, Gaskin CM, Taffoni MJ, Anderson
2004;46(2):138–44. MW. Little Leaguer's shoulder (proximal humeral
17. Yang LJ. Neonatal brachial plexus palsy--man- epiphysiolysis): MRI findings in four boys. Pediatr
agement and prognostic factors. Semin Perinatol. Radiol. 2007;37(9):885–9.
2014;38(4):222–34. 34. Krogstad P. Osteomyelitis. In: Feigin RD, Cherry JD,
18. Narakas AO. Injures to the brachial plexus. In: Demmler-Harrison GJ, Kaplan SL, editors. Textbook
Bora FWJ, editor. The pediatric upper extremity. of pediatric infectious diseases. 7th ed. Philadelphia:
Philadelphia: W.B. Saunders Co; 1986. p. 247–58. Saunders; 2014. p. 711–27.
19. Steens SC, Pondaag W, Malessy MJ, Verbist 35. Peltola H, Paakkonen M. Acute osteomyelitis in chil-
BM. Obstetric brachial plexus lesions: CT myelogra- dren. N Engl J Med. 2014;370(4):352–60.
phy. Radiology. 2011;259(2):508–15. 36. Krogstad P. Septic arthritis. In: Feigin RD, Cherry JD,
20. Hogendoorn S, van Overvest KL, Watt I, Duijsens AH, Demmler-Harrison GJ, Kaplan SL, editors. Textbook
Nelissen RG. Structural changes in muscle and gleno- of pediatric infectious diseases. 7th ed. Philadelphia:
humeral joint deformity in neonatal brachial plexus Saunders; 2014. p. 711–27.
palsy. J Bone Joint Surg Am. 2010;92(4):935–42. 37. Blickman JG, van Die CE, de Rooy JW. Current imag-
21. Moukoko D, Ezaki M, Wilkes D, Carter P. Posterior ing concepts in pediatric osteomyelitis. Eur Radiol.
shoulder dislocation in infants with neona- 2004;14(Suppl 4):L55–64.
tal brachial plexus palsy. J Bone Joint Surg Am. 38. Ogden JA. Pediatric osteomyelitis and septic arthritis:
2004;86-A(4):787–93. the pathology of neonatal disease. Yale J Biol Med.
22. Waters PM, Smith GR, Jaramillo D. Glenohumeral 1979;52(5):423–48.
deformity secondary to brachial plexus birth palsy. J 39. Caksen H, Ozturk MK, Uzum K, Yuksel S, Ustunbas
Bone Joint Surg Am. 1998;80(5):668–77. HB, Per H. Septic arthritis in childhood. Pediatr Int.
23. Poyhia TH, Nietosvaara YA, Remes VM, Kirjavainen 2000;42(5):534–40.
MO, Peltonen JI, Lamminen AE. MRI of rotator cuff 40. Devauchelle-Pensec V, Thepaut M, Pecquery R, Houx
muscle atrophy in relation to glenohumeral joint L. Managing monoarthritis in children. Joint Bone
incongruence in brachial plexus birth injury. Pediatr Spine. 2015;83:25.
Radiol. 2005;35(4):402–9. 41. Lejman T, Strong M, Michno P, Hayman M. Septic
24. Kozin SH. Correlation between external rotation of the arthritis of the shoulder during the first 18 months of
glenohumeral joint and deformity after brachial plexus life. J Pediatr Orthop. 1995;15(2):172–5.
birth palsy. J Pediatr Orthop. 2004;24(2):189–93. 42. Hemke R, Nusman CM, van der Heijde DM, Doria
25. Emery KH. MR imaging in congenital and acquired AS, Kuijpers TW, Maas M, et al. Frequency of joint
disorders of the pediatric upper extremity. Magn involvement in juvenile idiopathic arthritis dur-
Reson Imaging Clin N Am. 2009;17(3):549–70.. vii ing a 5-year follow-up of newly diagnosed patients:
26. Robinson TW, Corlette J, Collins CL, Comstock implications for MR imaging as outcome measure.
RD. Shoulder injuries among US high school Rheumatol Int. 2015;35(2):351–7.
43. Johnson K, Gardner-Medwin J. Childhood arthri- multifocal osteomyelitis. Curr Rheumatol Rep.
tis: classification and radiology. Clin Radiol. 2012;14(2):130–41.
2002;57(1):47–58. 51. Beretta-Piccoli BC, Sauvain MJ, Gal I, Schibler A,
44. Colebatch-Bourn AN, Edwards CJ, Collado P, Saurenmann T, Kressebuch H, et al. Synovitis, acne,
D'Agostino MA, Hemke R, Jousse-Joulin S, et al. pustulosis, hyperostosis, osteitis (SAPHO) syndrome
EULAR-PReS points to consider for the use of imag- in childhood: a report of ten cases and review of the
ing in the diagnosis and management of juvenile idio- literature. Eur J Pediatr. 2000;159(8):594–601.
pathic arthritis in clinical practice. Ann Rheum Dis. 52. Khanna G, Sato TS, Ferguson P. Imaging of chronic
2015;74(11):1946–57. recurrent multifocal osteomyelitis. Radiographics.
45. Weiss PF, Chauvin NA, Klink AJ, Localio R, Feudtner 2009;29(4):1159–77.
C, Jaramillo D, et al. Detection of enthesitis in chil- 53. Manson D, Wilmot DM, King S, Laxer RM. Physeal
dren with enthesitis-related arthritis: dolorimetry involvement in chronic recurrent multifocal osteomy-
compared to ultrasonography. Arthritis Rheumatol. elitis. Pediatr Radiol. 1989;20(1–2):76–9.
2014;66(1):218–27. 54. O'Brien SJ, Neves MC, Arnoczky SP, Rozbruck SR,
46. Martini G, Tregnaghi A, Bordin T, Visentin MT, Dicarlo EF, Warren RF, et al. The anatomy and histol-
Zulian F. Rice bodies imaging in juvenile idiopathic ogy of the inferior glenohumeral ligament complex of
arthritis. J Rheumatol. 2003;30(12):2720–1. the shoulder. Am J Sports Med. 1990;18(5):449–56.
47. Harty MP, Mahboubi S, Meyer JS, Hubbard AM. MRI 55. Helms CA. Benign lytic lesions. In: Fundamentals
of the pediatric shoulder: nontraumatic lesions. Eur of skeletal radiology [Internet]. 4th ed. Philadelphia:
Radiol. 1997;7(3):352–60. Saunders; 2014. p. 7–31.
48. Ferguson P, Laxer RM. Autoinflammatory bone 56. Wootton-Gorges SL. MR imaging of primary bone
disorders. In: Cassidy and Petty's textbook of pedi- tumors and tumor-like conditions in children. Magn
atric rheumatology [Internet]. 7th ed. Philadelphia: Reson Imaging Clin N Am. 2009;17(3):469–87, vi
Elsevier; 2015. p. 627–41. 57. Schuppers HA, van der Eijken JW. Chondroblastoma
49. Walsh P, Manners PJ, Vercoe J, Burgner D, during the growing age. J Pediatr Orthop B.
Murray KJ. Chronic recurrent multifocal osteo- 1998;7(4):293–7.
myelitis in children: nine years' experience at a 58. Jee WH, Park YK, McCauley TR, Choi KH, Ryu KN,
statewide tertiary paediatric rheumatology refer- Suh JS, et al. Chondroblastoma: MR characteristics
ral centre. Rheumatology (Oxford). 2015;54(9): with pathologic correlation. J Comput Assist Tomogr.
1688–91. 1999;23(5):721–6.
50. Ferguson PJ, Sandu M. Current understanding of the 59. Yaw KM. Pediatric bone tumors. Semin Surg Oncol.
pathogenesis and management of chronic recurrent 1999;16(2):173–83.
Imaging Diagnosis of Nerve
Entrapments in the Shoulder 14
Alireza Eajazi, Miriam A. Bredella,
and Martin Torriani
14.1 Introduction without associated sensory deficit, sharp burn-

ing pain, and paresthesias over a localized skin
Nerve injuries are an unusual source of shoulder area are a few signs and symptoms of entrap-
pain. They can result from several causes includ- ment neuropathies. Most of these cases are
ing trauma, neoplasia, infection, neuropathy, related to physical circumstances leading to a
autoimmune disease, and iatrogenic conditions nerve being stretched or compressed into a
[1]. Neuropathies of the shoulder are frequently fibrous or osteofibrous space. Particularly in
considered entrapment syndromes and account neuropathy of the suprascapular nerve, the clini-
for about 2% of cases of shoulder pain [2]. cal diagnosis is often delayed because of non-
However, this frequency is likely to be underes- specific symptoms [4–6].
timated because these conditions have been In this chapter, we review anatomic structures
overlooked in the past [3]. As a result of and landmarks of the most important nerves
increased familiarity regarding these conditions, around the shoulder. We also discuss the patho-
they are diagnosed with growing frequency in logic conditions causing entrapment neuropa-
patients with symptoms suggestive of nerve thies such as compression, stretching, or
pathology. iatrogenic lesions and outline different diagnostic
The most commonly affected nerves in the imaging modalities. Finally, we review specific
shoulder region are the suprascapular nerve, shoulder neuropathies and explain their MRI
axillary nerve, long thoracic nerve, cervical characteristics.
accessory nerve, and dorsal scapular nerve.
These nerves may be involved in patients engag-
ing in vigorous overhead activity, with massive 14.2 Pertinent Anatomy
rotator cuff tears, tears accompanied by fatty
infiltration and/or atrophy of muscle, labral tear 14.2.1 Suprascapular Nerve
and paralabral cyst formation, and space-
occupying lesions [3]. Muscle weakness with or The suprascapular nerve originates from the
upper trunk of the brachial plexus, with contribu-
tions from C5, C6, and sporadically C4 nerve
A. Eajazi · M. A. Bredella · M. Torriani (*)
Division of Musculoskeletal Imaging root (Fig. 14.1). It is responsible for motor inner-
and Intervention, Department of Radiology, vation of two rotator cuff muscles: the supraspi-
Massachusetts General Hospital and Harvard natus and infraspinatus. The nerve travels
Medical School, Boston, MA, USA posterior to the clavicle and obliquely traverses
e-mail: mbredella@mgh.harvard.edu;
mtorriani@mgh.harvard.edu towards the superior border of the scapula

322 A. Eajazi et al.
C4
ROOTS C5
C5
Dorsal C6
scapular
nerve C6
TRUNKS
C7
C7
C8
Supra-
DIVISIONS
scapular Upper T1
T1
nerve Middle
Lower
CORDS
Lateral
Posterior
TERMINAL Medial
NERVES
Long
thoracic
nerve
Axillary nerve
Radial nerve
Musculo-
cutaneous nerve Ulnar nerve
Median nerve
 Mayo Clinic
Fig. 14.1 Schematic representation of the anatomy of brachial plexus and its branches. Used with permission of Mayo
Foundation for Medical Education and Research. All rights reserved
(Fig. 14.2). The nerve then passes through the spinoglenoid ligament (inferior transverse liga-
suprascapular notch in an anterior-to-posterior ment) to provide branches to the infraspinatus
direction. Generally, the nerve travels beneath the muscle.
transverse scapular ligament in the suprascapular The presence of these two anatomical notches
notch, while its associated artery passes over the and the awareness of local muscle innervation
ligament. Branches to the supraspinatus muscle patterns can assist the physician in diagnosing
emanate posterior to the suprascapular notch. specific conditions. The role of these notches in
The nerve continues towards the spinoglenoid entrapment neuropathies was first suggested by
notch of the scapula, where it travels beneath the Aiello et al. [7] who discriminated between
14 Imaging Diagnosis of Nerve Entrapments in the Shoulder 323
Dorsal Scapular n. and a. Supraspinatus m. Suprascapular n. and a.

Supraspinatus Suprascapular notch and
branch transverse scapular ligament
Levator Scapulae m.
Spinoglenoid notch
Rhomboid Minor m.
Infraspinatus
branches
Rhomboid Major m. Infraspinatus m.
Fig. 14.2 Schematic representation of shoulder nerves and branches. Note the relationship between the suprascapular
nerve with the suprascapular and spinoglenoid notches
entrapment of the nerve at the suprascapular to the superior glenoid rim. As the suprascapular
notch and entrapment at the spinoglenoid notch. neurovascular bundle arrives in the spinoglenoid
Although the suprascapular nerve has been con- notch, it can be seen on axial MRI images.
sidered a pure motor nerve, cadaveric studies A noticeable suprascapular vein, which occa-
have indicated sensory branches to the glenohu- sionally is responsible for compressive neuropa-
meral joint, acromioclavicular joint, coracoac- thy, is in some instances noted in the proximity of
romial ligament, and skin [8, 9]. Improved the nerve.
anatomic recognition of the sensory contribu-
tions of the suprascapular nerve helped to clar-
ify the associated pain resulting from injury or 14.2.2 Axillary Nerve
traction of this nerve. Up to 70% of the sensa-
tion of the shoulder may be provided by the The axillary nerve is a final branch of the posterior
suprascapular nerve [10], and studies have cord of the brachial plexus and originates from the
shown improved postoperative pain after supra- ventral rami of C5 and C6 (Fig. 14.1). The first
scapular nerve block in patients who had shoul- portion of the axillary nerve is located lateral to the
der surgery [11, 12]. radial nerve, posterior to the axillary artery, and
The suprascapular nerve and its concomitant anterior to the subscapularis muscle. It continues
vessels, well delineated by fat, are originally best in an oblique direction across the inferolateral bor-
identified on oblique coronal T1-weighted MRI der of the subscapularis. It then travels through the
showing the suprascapular notch, at the junction quadrilateral space associated with the posterior
of the glenoid with the scapular neck, just medial humeral circumflex artery (Fig. 14.3). The quadri-
Fig. 14.3 Coronal

oblique T1-weighted
image of the right
shoulder showing the
teres major (Tmaj), teres
minor (Tmin), triceps
(arrow), and humerus
(H) delimiting the
quadrilateral space
(curved arrow), where
the posterior circumflex
vessels and axillary
nerve are identified
lateral space is a rectangular cuboid, located infer- depicted next to the medial humeral cortex and lat-
oposterior to the glenohumeral joint, with mean eral to the long head of the triceps muscle on oblique
dimensions of about 2.5 × 1.5 cm [13, 14]. It is coronal images oriented along the humeral shaft.
bordered superiorly by the teres minor muscle,
inferiorly by the teres major muscle, medially by
the long head of the triceps, and laterally by the 14.2.3 Long Thoracic Nerve
surgical neck of the humerus [15]. The axillary
nerve is the most superior structure in this space The long thoracic nerve is a pure motor nerve
[13], where the nerve divides into its anterior particularly responsible for innervation of the
(superior) and posterior (inferior) branches [14]. serratus anterior muscle. Anatomically, it origi-
The anterior branch takes a circuitous route around nates from C5 to C7 and occasionally C8 (8%)
the surgical neck of the humerus and provides (Fig. 14.1) [16]. After advancing anteriorly to the
branches for the anterior and middle parts of the posterior scalene muscle, it travels distally and
deltoid muscle. The posterior branch supplies the laterally to pass below the clavicle and under the
subscapular muscle, the teres minor muscle, and first and the second ribs. Distally, the nerve
often the posterior portion of the deltoid, as well as descends along the chest wall in the midaxillary
sensory innervation of the posterolateral shoulder. line to the outer border of the serratus anterior,
The axillary neurovascular bundle is best identi- sending branches to each of the digitations of this
fied on oblique sagittal T1-weighted MRI of the muscle (Fig. 14.4) [16]. The serratus anterior
shoulder. It is well highlighted by surrounding fat muscle originates from the costomedial border of
and is seen below the inferior glenoid rim passing the scapula and inserts on the first through ninth
through the space between the teres minor and the ribs, forming the medial wall of the axilla and
teres major muscles. The quadrilateral space is best functioning as a scapular protractor.
of shoulder nerves [17]. It is a pure motor nerve

originating from C1 to C4 cervical segments and
ascends through the foramen magnum, and returns
through the jugular foramen. After providing
motor innervation to SCM muscle, it enters the
posterior triangle of the neck and eventually inner-
vates the trapezius muscle. Additionally, the nerve
proceeds caudally and dorsally in the subcutane-
ous tissue along the posterior triangle of the neck.
14.2.5 Dorsal Scapular Nerve
The dorsal scapular nerve is a motor nerve that

arises from the C5 nerve root, with usual contri-
bution from C6 (Fig. 14.1). After its origin, it
runs in close proximity of the upper trunk of the
brachial plexus, then traversing the middle sca-
Fig. 14.4 Topographical anatomy of the long thoracic
nerve, overlying the serratus anterior muscle. Used with lene muscle and traveling posteriorly to inner-
permission of Mayo Foundation for Medical Education vate the levator scapula muscle. The nerve also
and Research. All rights reserved reaches the deep surfaces of rhomboid major and
minor, supplying both muscles that have a role in
moving the scapula medially (Fig. 14.2) [13].
14.3 Pathologic Conditions
14.3.1 Definition
The term entrapment neuropathy refers to an iso-

lated peripheral nerve injury at a specific location
where a mechanical constriction occurs, most
commonly from a fibrous or fibro-osseous tunnel,
or by a fibrous band. However, there are cases in
which the nerve is injured by chronic direct com-
pression by space-occupying lesions (such as a
Fig. 14.5 Topographical anatomy of the accessory nerve cyst), or by chronic deformation, angulation, or
as it travels along the posterolateral neck. Used with per- stretching forces causing mechanical damage.
mission of Mayo Foundation for Medical Education and Finally, iatrogenic causes can result in the nerve
Research. All rights reserved injury, including direct nerve injury or by means
of deformation induced by postsurgical scarring.
14.2.4 Spinal Accessory Nerve
14.3.1.1 Nerve Compression
The spinal accessory nerve is a cranial nerve (CN Entrapment neuropathies of the shoulder sec-
XI) originating from the upper segments of the ondary to nerve compression by mechanical or
spinal cord, ultimately supplying motor fibers to dynamic forces could be a cause of upper
the sternocleidomastoid (SCM) and trapezius extremity weakness and pain in the athlete.
muscles (Fig. 14.5), being included in the gamut Structurally narrow tunnels make individual
nerves susceptible to entrapment neuropathies. 14.3.2 Radiographs and Computed

Dynamic changes within these narrow passages Tomography
during repetitive athletic activity can create
further compression of a nerve with only mini- The decision on the timing and modality of
mal anatomic variation [18]. Nerve compression shoulder imaging is based on multiple factors,
may also be produced by space-occupying including the acuity of the injury, the suspected
lesions such as cysts, tumors, and inflammatory tissue and nerve involved, the age of the patient,
processes or by posttraumatic conditions such as and demands that the patient applies on the shoul-
hematoma, myositis ossificans, and scar forma- der. In general, acute traumatic injuries are
tion. Direct compression occurs mainly because imaged with plain films to exclude fracture or
a space-occupying lesion evolves in the proxim- dislocation. For several bone and joint problems,
ity of the nerve, which can also develop if local radiographs are often the only required imaging
anatomy has been altered by a fracture. Other study, being noninvasive and rather inexpensive
causes for nerve compression are associated compared to other imaging studies. They should
with hormonal alterations and systemic diseases, be obtained to rule out likely osseous causes of
such as pregnancy, oral contraceptive ingestion, nerve entrapment and to evaluate concomitant
diabetes mellitus, and hypothyroidism. shoulder conditions, such as glenohumeral sub-
luxation or osteoarthritis. Several views of the
14.3.1.2 Nerve Stretching shoulder are necessary for comprehensive visual-
Along the trajectory of nerves, there are fixed ization of the osseous and articular anatomy.
points limiting its mobility potentially predispos- A Stryker notch view allows evaluation of the
ing to focal deformation that exceeds its mechani- suprascapular notch and may display complete
cal properties. Specific repetitive movements can ossification or near obliteration of its foramen.
create excess nerve traction, causing strain injuries A suprascapular notch view (X-ray beam directed
at these fixed points, evolving with inflammation 15–30° cephalad) allows visualization of osseous
that impairs normal nerve conduction. Additional notch variants. Anteroposterior radiographs
factors, such as fibrous bands or small arterial directly show superior migration of humeral head
branches crossing a nerve, can create additional suggestive of chronic rotator cuff disease.
fixed points and also be the basis for entrapments. Appropriate evaluation of conventional radio-
graphs often encourages selection of higher level
14.3.1.3 Iatrogenic Lesions imaging studies. In situations in which osseous
Iatrogenic lesions from surgery can also be a abnormalities are speculated to be the primary
source for shoulder neuropathies. For example, purpose of nerve injury, a computed tomography
the spinal accessory nerve may be injured after (CT) scan may be beneficial in recognizing spe-
biopsies of a cervical lymph node. Neurologic cific regions of likely nerve compression [26].
symptoms are present after approximately 0.2– Radiographs are not well suited for suspected
3% of shoulder arthroscopic procedures, 4% of nerve injuries of insidious onset given their pref-
arthroplasties, and 8% of open surgeries for the erential involvement of soft tissues.
treatment of instability [19–21]. The majority of CT scans allows for excellent detail regarding
these injuries are minor cutaneous nerve lesions osseous pathology in addition to reliable identi-
and transient neurapraxias [22–25]. Permanent fication of muscular fatty degeneration and atro-
sequelae and injuries that require secondary sur- phy. Although CT has limitations in directly
gical intervention are rare, and the long-term out- assessing shoulder nerves, this method provides
comes of patients with nerve injury from shoulder excellent visualization of suprascapular and
surgery have been rarely reported. These situa- spinoglenoid notches. In addition, CT arthrogra-
tions are less diagnostically challenging. phy can help diagnose paralabral cysts, in
p articular those communicating with the gleno- B- Supraspinatus and infraspinatus muscles
humeral joint, as well as identify rotator cuff compared to contralateral side. Muscle atrophy
tears as a potential source of shoulder pain. can be readily determined with asymmetry of
A low-dose CT scan can concurrently analyze muscle volume, along with fatty degeneration
the position of the scapula and the attached mus- that causes increased echogenicity. This can be
cles and look for signs of denervation (fatty done rapidly at the end of ultrasound examination
degeneration, etc.) and dynamic 3-dimensional while evaluating the posterior aspect of the gle-
(4D) reconstructions obtained with a large detec- nohumeral joint.
tor CT scanner can demonstrate scapular kine- Although this methodology only relates to
matics in suspected scapular winging [2, 27]. suprascapular neuropathy, it can be valuable
since this nerve can account for up to 97% of
shoulder entrapment neuropathies. A direct
14.3.3 Ultrasound search for specific nerves can be performed as
needed but access can be limited by the complex
Ultrasound is an excellent imaging modality to nerve trajectory, depth, and overlapping osseous
assess muscle, ligament, and tendon anatomy, anatomy [29].
with the unique advantage of allowing for
dynamic imaging studies. In the shoulder, ultra-
sound has consistently demonstrated high lev- 14.3.4 Magnetic Resonance Imaging
els of accuracy to detect rotator cuff pathology.
However, this modality still has a limited role Besides providing direct visualization of a nerve
in comprehensively assessing the shoulder for and surrounding tissues, MRI is able to illustrate
entrapment neuropathies, given the difficulty in intrinsic signal abnormalities within the nerve
reliably demonstrating variable levels of mus- and is considered superior in defining the associ-
cle edema and directly showing the challenging ated indirect signs from muscle denervation [30,
anatomy of shoulder nerves throughout their 31]. The signal intensity of a normal nerve on
entire course. Nevertheless, shoulder ultra- MRI is intermediate to low on T1-weighted
sound can be used as a first intention modality sequences being slightly higher on T2-weighted
for shoulder pain to rule out confounding symp- and other fluid-sensitive sequences [31, 32].
toms. Although the initially suspected diagno- Enlargement with obvious increase in T2 signal
sis is often a rotator cuff tendon tear, the is regarded as an abnormal MRI appearance
radiologist must not ignore differential diagno- [32]. Additionally, a hyperintense signal of the
ses that could relate to a neuropathy, particu- denervated muscle is commonly seen when
larly when no cuff tendon abnormality has been entrapment is acute, and fatty infiltration and
identified. For this reason, beyond the standard muscle atrophy are signs of long-standing neu-
assessment for rotator cuff and biceps tendons, ropathy in chronic cases [30–32]. Recognizing
it is suggested to systematically include the fol- muscular denervation (muscular edema, atrophy,
lowing items in a shoulder ultrasound examina- and fatty degeneration) in a neural distribution
tion [28]: pattern is essential to the diagnosis of entrap-
A- Suprascapular and spinoglenoid notches to ment neuropathies. MRI is the only imaging
assess for a space-occupying lesion. A paralabral modality that can reliably detect muscular
cyst can be readily differentiated from dilated edema, which is the earliest abnormality to
suprascapular veins by combining color Doppler appear in entrapment neuropathies. MRI also
and compression of the structure; veins are filled allows an assessment of the severity of the dis-
with colored Doppler flow signal and collapse ease and the search for its etiology, being valu-
under pressure, whereas cysts do not. able in excluding differential diagnoses. The
MRI protocol should be adjusted to each situa- Experimental studies show that muscle edema
tion: in case of suspected suprascapular or axil- peaks 2–4 weeks after the primary trauma but its
lary neuropathy, the field of view (FOV) has to intensity increases with the severity of lesions
be centered on the glenohumeral joint, while in [33]. In sports-related shoulder neuropathy, this
case of scapular winging the FOV needs to be anomaly can be seen beyond 6 months [5].
enlarged to cover both scapulae and their attach- Denervated muscle atrophy typically pro-
ing posterior and medial muscles. gresses slower than edema. Atrophy is best
shown on sagittal T1-weighted images due to
14.3.4.1 Building an MRI Protocol the optimal contrast between muscle and sur-
The most important pulse sequence is fast spin- rounding fat. The sagittal plane grants a com-
echo T2-weighted imaging with fat suppression, parison among scapular muscles, which are
carried out in the axial plane. This imaging visualized along their short axes, allowing for
allows the recognition of muscular edema, using an estimation of their bulk. The degree of atro-
echo times ≥45 ms for sufficient T2 weighting phy can be assessed by examining the muscle
[2]. T1-weighted sequences without fat suppres- surfaces, which are normally convex but turn
sion are also important for the diagnosis of mus- flat and ultimately concave in the later stages
cle fatty degeneration. Acquisition in the sagittal [5]. Atrophic pseudohypertrophy has been
plane may be supplementary to grant better described in which the afflicted muscle para-
comparisons between the different muscles, doxically enlarges in response to denervation;
particularly if the signal abnormalities are however it is diffusely infiltrated by adipose tis-
slight. It is reasonable to increase the gap sue [1]. However, unlike true muscle hypertro-
between the slices to cover the total volume of phy in which the signal is normal on all MRI
the muscles, given that shoulder muscle may be sequences, the pseudohypertrophied muscle
partially involved with edema or chronic atro- loses its normal signal intensity because of
phy, depending on the site of entrapment. edema and fatty replacement. Fatty degenera-
Typically, intravenous injection of gadolinium tion initiates during the subacute phase and is a
injection is not required for the assessment of hallmark of chronic muscle denervation [30].
shoulder neuropathies. However, denervated Rotator cuff muscle fatty degeneration can be
muscles frequently show contrast enhancement, measured on sagittal T1-weighted images using
making such images comparable to those the Bernageau and Goutallier classification
obtained with T2-weighted fat-suppressed pulse method [34].
sequences [1, 27].
The edema observed in entrapment neuropa-
thies has many specific features [2]: it involves 14.3.5 Specific Shoulder
only the denervated muscles, being homoge- Neuropathies and Related
neous in intensity and affecting the muscle dif- MRI Features
fusely. Muscle edema from neuropathies is an
early phenomenon. Clinical studies report it to be 14.3.5.1 Suprascapular Nerve
detectable in the second week after trauma or at Neuropathies
the onset of electromyography (EMG) abnormal-
ities, but in experimental studies it manifests ear- Suprascapular Nerve Syndrome
lier, up to a few days after trauma [33]. The suprascapular nerve can be injured by sev-
Neuropathic muscle edema is also isolated eral mechanisms. These include repetitive over-
because of the lack of other intramuscular abnor- head sports or activities and associated nerve
malities. The intensity of edema relies upon the traction [35–38], compression from a space-
severity and duration of the primary lesion. occupying lesion such as a cyst [39–41], trauma
[42–45], and rotator cuff tears [46]. Athletes their deep location, depiction of paralabral cysts
who perform repetitive overhead activities such requires a careful scanning technique with ultra-
as tennis and volleyball have been described to sound [63]. Varicose veins in the spinoglenoid
experience neuropathy secondary to traction notch are the main differential diagnosis.
and microtrauma [35, 47, 48]. The mechanism Although enlarged spinoglenoid notch veins
is increased pressure on the nerve by the spino- look like a cyst because they appear as fluid-
glenoid ligament when the shoulder is in a posi- filled images, they change their shape, collaps-
tion of overhead throwing [49]. Traction injury ing in internal rotation of the arm and dilating
can also happen in the presence of a retracted maximally in external rotation [64].
superior or posterior rotator cuff tear. The sec- Historically, suprascapular neuropathy was
ondary traction of the nerve is created at the speculated as a diagnosis of exclusion; however
suprascapular notch or around the base of the several studies have shown multifactorial causes
scapular spine. Repetitive adduction and inter- of suprascapular neuropathy. Other sources of
nal rotation of the shoulder can stretch the nerve suprascapular neuropathy include intimal dam-
below the spinoglenoid ligament [50]. age to the suprascapular artery resulting in
Ossification of the transverse scapular ligament microemboli in the vasa nervorum [37], gleno-
or spinoglenoid ligament at the suprascapular or humeral dislocation [43–45], fractures around
spinoglenoid notch, respectively, may increase the shoulder girdle [42, 65, 66], and penetrating
the risk of suprascapular neuropathy [36, 51– injury to the shoulder or surgical procedures
54]. This may create stretching and compression using a posterior approach to the scapula [67].
of the suprascapular nerve and its branches The clinical and imaging characteristics of
below the suprascapular ligament. Nerve com- entrapment neuropathies of the suprascapular
pression may also happen at either the supra- nerve and its branches differ, depending on the
scapular or the spinoglenoid notch by soft-tissue location of compression, traction, or injuries.
or bone tumor, or a cyst secondary to a labral or Entrapment of the suprascapular nerve at the
capsular injury [39–41]. scapular notch leads to supraspinatus and infra-
The association between labral tears and para- spinatus muscle denervation, while distal
labral cysts causing suprascapular neuropathy is entrapment at the spinoglenoid notch typically
well determined in both radiographic and clinical causes isolated involvement of the infraspinatus
investigations [55–59]. muscle [68].
Paralabral cysts are usually associated with MRI is a valuable diagnostic modality in
tears of the superior and posterior glenoid patients who have suprascapular nerve entrap-
labrum (from 8- to 11-o’clock positions), related ment. The MRI characteristics of compressive
to the passage of joint fluid into the cyst through neuropathy consist of direct signs involving the
a thin pedicle [60, 61]. During their growth, nerve and indirect signs pertaining to muscle
paralabral cysts may spread into the spinogle- denervation. Abnormalities in the signal inten-
noid notch, the suprascapular notch, or both, sity, size, and position of the affected nerve are
possibly causing nerve entrapment and muscle direct signs of peripheral nerve entrapment [6].
denervation. Ultrasound and MRI can identify The structural causes may be displayed including
the cyst and recognize secondary changes of space-occupying lesions, such as ganglia and
nerve damage, including loss in bulk and tumors, or osseous abnormalities, such as bony
echotextural or signal intensity changes in the spurs, fracture fragments, and callus. Ganglia are
innervated muscles due to edema and fatty isointense or hypointense in comparison with
replacement [62]. A direct correlation has been muscle on T1-weighted images, are homoge-
found between the size of paralabral cysts and neously hyperintense on T2-weighted sequences,
the onset of denervation symptoms [60]. Due to and show thin peripheral enhancement with
a b
Fig. 14.6 30-Year-old male: (a) Coronal oblique T2 fast gesting involvement of the infraspinatus branch of the
spin echo showing a hyperintense large cyst occupying suprascapular nerve. (c) STIR sagittal oblique image
the spinoglenoid notch (arrow). (b) T1-weighted sagittal shows the cyst (arrow) in spinoglenoid notch with second-
oblique image shows the cyst as a low/isointense mass ary edema of the upper portion of infraspinatus muscle
(arrow) and mild atrophy of the upper infraspinatus mus- (IS, curved arrow)
cle. The supraspinatus muscle (SS) appears normal sug-
gadolinium (Figs. 14.6 and 14.7). The pattern of at the suprascapular notch, while isolated involve-
muscle denervation provides information about ment of infraspinatus reflects compression at the
the duration of entrapment and can identify the spinoglenoid notch [6].
location of neurologic compromise. Acute dener-
vation is demonstrated as hyperintensity of the 14.3.5.2 Axillary Nerve Neuropathies
supraspinatus and infraspinatus or infraspinatus Axillary neuropathy can be secondary to stretch-
muscle alone on fluid-sensitive sequences. ing injures or extrinsic compression in the quadri-
Chronic compression is displayed as a reduction lateral space induced by humeral fractures,
in muscle bulk and fatty infiltration of the improper use of crutches, casts, fibrous bands,
involved muscles. Involvement of both the supra- space-occupying lesions, and inferior paraglenoid
and infraspinatus muscles indicates compression cysts [16, 69]. Iatrogenic nerve injury during
a b
Fig. 14.7 39-Year-old male showing (a) coronal oblique lar notch. (b) Sagittal oblique STIR image shows diffuse
T2-weighted FSE fat-suppressed image in which a mul- neurogenic edema involving the infraspinatus muscle
tiloculated cyst (curved arrow) involves the suprascapu- (arrow)
arthroscopic procedures around the coracoid or was first explained by Cahill and Palmer [70] in
by posterior surgical arthroscopic portals has also 1983 in which the neurovascular bundle, con-
been described [16]. When entrapment of the axil- taining the axillary nerve and posterior humeral
lary nerve happens in the quadrilateral space, circumflex artery, is compressed by fibrous
there is isolated denervation of the teres minor bands as it travels through the quadrilateral
muscle because the anterior branch of the nerve space. It commonly occurs in young athletes
(supplying the deltoid) is spared (Fig. 14.8). between the ages of 25 and 35 years without a
Axillary neuropathy may be identified inciden- history of serious trauma. The syndrome is
tally during routine MRI of the shoulder, since determined clinically by poorly localized
clinically this may not be apparent because the anterolateral shoulder pain and is aggravated by
action of teres minor cannot be definitely sepa- forward flexion, abduction, and external rota-
rated from the contribution of infraspinatus. When tion of the humerus. This pain is typically asso-
symptomatic, axillary neuropathy appears with ciated with point tenderness over the posterior
ambiguous, often nonspecific posterior shoulder shoulder, near the teres minor insertion site.
pain, sensory disturbances over the external aspect Skin paraesthesia in the sensory distribution of
of the shoulder, and weakness aggravated by the axillary nerve (overlying the deltoid mus-
overhead activity and heavy lifting. Even without cle) and atrophy or weakness of the teres minor
any noticeable soft-tissue abnormality along the and deltoid may occur as well [71]. The devel-
nerve course, the imaging diagnosis of axillary opment of fibrous bands in the quadrilateral
neuropathy is based on the signs of volume loss space sounds to be related to microtrauma due
and signal alteration of the affected muscles in the to repeated overhead activity such as throwing
absence of a tendon tear [6]. [72, 73]. Although extrinsic compression by
fibrous bands is the most common cause of the
Quadrilateral Space Syndrome syndrome, various other causes have now been
Quadrilateral space syndrome is a rare condi- discussed in the literature. Robinson et al. [74]
tion referring to an isolated compressive neu- were the first to report a case of quadrilateral
ropathy of the axillary nerve. The syndrome space syndrome caused by a paralabral cyst.
a b
Fig. 14.8 43-Year-old male showing (a) coronal oblique ary edema of the teres minor muscle (b) (curved arrow).
T2-weighted FSE images with multiloculated cyst that dis- (c) Sagittal T1-weighted image shows loss of bulk of the
sected towards the quadrilateral space (arrow) and second- teres minor muscle with fatty infiltration (curved arrow)
Juxta-articular cysts are a typical entity occur- joint [75]. When large, inferior labral cysts can
ring next to large joints and are a well-estab- create mass effect on the neurovascular bundle
lished reason of compressive suprascapular in the tightly constrained quadrilateral space.
neuropathy in the shoulder. Glenoid labral cysts Quadrilateral space masses such as soft-tissue
are thought to arise from extrusion of joint fluid tumors and hematomas have also been described
via labrocapsular tears. They develop most to result in this syndrome. Other reported cases
commonly in the superior and posterior aspects of axillary nerve injury include trauma (humeral
and are infrequent in the inferior region of the neck or scapular fractures), acute translational
incidents such as glenohumeral subluxation or eral space. The risk for axillary nerve and bra-
anterior dislocation, and surgical or arthroscopic chial plexus injury is higher if the shoulder is not
intervention [76–78]. The relatively fixed posi- reduced within 12 h. In spite of the high preva-
tion of the quadrilateral space makes it particu- lence of axillary nerve injury following shoulder
larly susceptible, and such injuries usually dislocation, only a few reports in the radiological
affect both the teres minor and deltoid muscles literature address the association of teres minor
due to the level at which the axillary nerve atrophy with prior dislocation [76, 82]. Traction
injury happens [79, 80]. and compression of the axillary nerve and sub-
The diagnosis of quadrilateral space syn- scapularis muscle can be induced by the
drome may be difficult on the basis of clinical dislocated humeral head or during manipula-

examinations alone and is typically one of exclu- tive reduction in which traction with rotation
sion. Generally poorly localized shoulder pain or abduction is concurrently performed.
may be confused with a rotator cuff injury or Posttraumatic injury to the axillary nerve can
impingement. When a clear structural lesion also be secondary to proximal humeral fracture
such as fibrous bands or a mass is discovered on [66], and seldom due to a direct blow to the del-
imaging, diagnosis can be relatively easy. MRI is toid muscle. The clinical diagnosis of axillary
superior to ultrasound to display any space- nerve injury may be difficult because the signs
occupying lesion in the quadrilateral space, such and symptoms are often ambiguous. Because
as paralabral cysts extending off the inferior branches to the lateral cutaneous innervation and
aspect of the glenoid in association with a tear of to teres minor muscle are closest to the glenoid
the inferior labrum [63, 76, 81]. However, MRI rim, they are most vulnerable to posttraumatic
generally shows no structural abnormality within injuries [83]. Injury to the infraspinatus muscle,
the quadrilateral space but may display second- however, may be clinically overlooked.
ary features of denervation myopathy. These MRI may illustrate signs suggestive of teres
characteristics include atrophy of the teres minor minor denervation injury with increased signal
and, less frequently, of the deltoid, which is seen on water-sensitive images or atrophy of the mus-
as a reduction in muscle volume and fatty degen- cle. Unlike EMG studies, which can directly
eration with chronic compression [71]. Fatty assess the function of nerves, MRI provides indi-
degeneration is best observed on T1-weighted rect indicators of nerve injury by finding changes
sequences but can also be viewed as abnormal in fat and water composition of muscle. Effects
signal intensity within the muscle belly on to T1 and T2 prolongation can be recognized
T2-weighted images (Fig. 14.8). Quadrilateral within 15 days post-injury [69, 84]. Most
space syndrome is a potentially reversible cause typically, isolated fatty atrophy of the teres

of shoulder pain. It should be considered when minor muscle is incidentally identified
selective atrophy or a signal change of teres (Fig. 14.9). The diagnosis of teres minor atrophy
minor with or without involvement of the deltoid in the absence of quadrilateral space lesions
is observed in the appropriate clinical setting. should prompt accurate assessment for signs
Other diagnoses producing muscle atrophy or suggestive of posttraumatic glenohumeral insta-
neurogenic edema in the absence of a clear bility and prior dislocation [76, 82, 85].
cause, such as traumatic injury to the axillary
nerve, brachial plexus, or nerve roots, must also 14.3.5.3 Scapular Winging
be considered [81]. Entrapments of the long thoracic, accessory, or
dorsal scapular nerves directly prevent scapular
Posttraumatic Axillary Nerve Injury movements due to the muscles involved. These
Up to 45% of shoulder dislocation cases may entrapments account for the static or dynamic
have associated nerve injury [44]. The axillary scapular prominence recognized as scapular
nerve is most commonly involved, because it has winging. This clinical condition is distinct from
a relatively tethered course within the quadrilat- suprascapular and axillary nerve entrapment
Fig. 14.9 36-Year-old male T1-weighted sagittal oblique

image showing isolated atrophy of the teres minor muscle
(curved arrow). SS, supraspinatus muscle, IS infraspina-
tus muscle
Table 14.1 Classification of scapular winging [2, 96]

Fig. 14.10 13-Year-old female with clinical evidence of
Primary scapular winging
left scapular winging after a fall. Coronal (a) and axial (b)
Neurologic origin Spinal accessory nerve (trapezius T2-weighted images show left scapular winging (curved
palsy) arrow) characterized by deformity and scapular malalign-
Long thoracic nerve (serratus ment without muscle edema
anterior palsy)
Dorsal scapular nerve
(rhomboids palsy)
The MRI protocol should be adjusted in case of
Osseous origin Osteochondromas scapular winging. In this case the FOV has to be
Fracture, malunions expanded to include both scapulae, covering the
Soft-tissue origin Contractural winging posterior and medial muscles attaching to them.
Muscle avulsion or agenesis The serratus anterior, the rhomboid muscles, and
Scapulothoracic bursitis the trapezius should be inspected (Fig. 14.11).
Secondary Accompanies glenohumeral Because this coverage is beyond the reach of a
scapula winging disorders and should resolve
once that disorder has been
dedicated shoulder coil, a multichannel phased
addressed array body coil should be used and the whole
Voluntary scapula winging width of the scapular girdle must be viewed.
Craniocaudally, the investigation must range from
the upper edge of the shoulder to the tip of the
because there is a clinical abnormality suggestive scapula. This allows a comparison between both
of it, which can be identified on physical exami- sides, which can be helpful when dealing with
nation (Fig. 14.10). The patient is likely to be subtle abnormalities. T2-weighted images with fat
referred for the exploration of this abnormality suppression and T1-weighted images are per-
[27] (Table 14.1). formed in the axial and sagittal planes.
a b
Fig. 14.11 45-Year-old male with right-shoulder pain and weakness with scapular winging for a month. (a) Axial
STIR and (b) coronal T1-weighted MRI show diffuse neurogenic edema involving right trapezius muscle (arrow)
Long Thoracic Nerve Neuropathy especially when the patient extends his or her
Long thoracic neuropathy most often results arms and pushes against a wall [88]. Direct
from repeated microtrauma due to stretching assessment of the long thoracic nerve is possible
injury. This usually occurs in athletes (e.g., only in part and for limited segments with ultra-
throwing sports such as javelin, baseball, or when sound. The diagnosis basically will be confirmed
serving or spiking a tennis or volleyball ball) by EMG or MRI, which demonstrates signs of
when the head is tilted and rotated laterally away denervation (edema, atrophy) of the serratus
from the affected extremity and the arm is ele- anterior muscle. The serratus anterior muscle is
vated overhead [16]. Direct trauma over the upper sometimes outside the usual scope of exploration
anterior chest and whiplash injury may also cause of the shoulder and standard joint examination
nerve compression [86]. Nontraumatic causes may miss the anomaly. A shoulder coil with a
consist of compression by enlarged bursae, such large field is sufficient in thin patients. A spine
as the subcoracoid bursa or the subscapularis coil and a multielement body coil will give satis-
recess. Irrespective of mechanism, it is still factory results in larger subjects. MRI also allows
unknown where the injury occurs along the for elimination of alternative causes of scapular
course of the nerve. Injury to the long thoracic winging.
nerve paralyzes the anterior serratus muscle,
which causes medial winging of the scapula and Accessory Nerve Neuropathy
a deficit in active forward flexion, which is more Spinal accessory nerve neuropathy most fre-
common than lateral winging. The scapular quently follows a stretch injury associated with
asymmetry (diagnosed by comparing the dis- lifting, heavy load bearing on the shoulders,
tance between the spinal processes and the medial whiplash, or trauma [89]. It has also been referred
edge of the scapula on both sides) may be clini- to skull deformities, infiltrative lesions, and radi-
cally evident on physical examination. It can be ation fibrosis [90]. Moreover, it may follow oper-
aggravated more on forward flexion of both arms ations involving the head and neck in which the
or by the wall push-up test. In the most severe dissection of a lymph node occurs. Patients pres-
cases, thorough elevation of the arm may be ent with mild shoulder droop, weakness of shoul-
impossible [87]. Physical examination shows an der elevation, and scapular winging during
obvious clinical picture with scapular winging, shoulder abduction. Atrophy of the trapezius
muscle causes scapular instability and painful Parsonage and Turner [98] in 1948 who described
shoulder abduction [17]. Lateral scapular wing- the condition in 136 servicemen, which they
ing is always present [91]; however only more called “neuralgic amyotrophy” or “shoulder-
severe types like the “droopy shoulder” may be girdle syndrome.” Afterwards, the pathology has
observed, associated with trapezius atrophy, commonly been referred to as Parsonage-Turner
shoulder drop, and lateral winging. Abduction syndrome or acute brachial neuritis, although the
and external rotation against resistance aggravate terms “brachial plexus neuropathy” [99], “acute
the scapular displacement, while forward flexion brachial radiculitis” [100, 101], and “paralytic
reduces the deformation because of serratus ante- brachial neuritis” [102, 103] have all been used to
rior contraction [29]. MRI is indicated in difficult describe the entity. Clinical diagnosis may be dif-
cases to confirm the diagnosis. Focused on the ficult because symptoms can simulate those of
trapezius and anterior serratus muscles, it shows more common disorders such as cervical spondy-
classic signs of denervation affecting the trape- losis, rotator cuff tears, impingement syndrome,
zius and allows for exclusion of long thoracic adhesive capsulitis, and calcific tendinitis [97–
neuropathy. 99, 104]. The exact cause of Parsonage-Turner
syndrome is unclear, although viral neuritis [99,
Dorsal Scapular Nerve Neuropathy 105], immunization [102], autoimmune mecha-
The dorsal scapular nerve supplies the rhom- nisms [106], trauma, strenuous exercise, and sur-
boids and is rarely injured in isolation, being gery [107] have all been noted. Prior infection
generally involved with a C5 radiculopathy. has been reported in up to 25% of cases [99]. The
Reports have been made of injury of the dorsal overall incidence has been estimated at 1.64 per
scapular nerve due to muscle hypertrophy in 100,000 individuals in one population [108]. The
bodybuilders [92]. Neuropathies of the dorsal age range of affected patients is very wide, with
scapular nerve are uncommon but their fre- most patients presenting in the third to seventh
quency is perhaps underestimated because their decades of life [104, 109]. Males are mostly
impact is generally minor [93]. They result in affected; bilateral involvement is observed in up
denervation of the rhomboids, which clinically to one-third of patients [99, 108]. Originally the
leads to discomfort or pain in these muscles, long thoracic nerve was thought to be the most
minimal scapular winging, and difficulty on arm commonly involved in Parsonage-Turner syn-
elevation. The location of nerve compression is drome [98]. However, future studies showed that
unclear, but could be a specific form of thoracic the most frequently involved muscles are those
outlet syndrome in the scalene space [94]. One innervated by the suprascapular nerve (supraspi-
article reports diagnostic confirmation of dam- natus and infraspinatus) [109], although the
age to this nerve by MRI [95], the positive find- entire brachial plexus can be affected. In a study
ing being thinner rhomboid muscles on MRI of of 27 patients with Parsonage-Turner syndrome,
the thorax. In addition, T2-weighted images may Gaskin and Helms [110] found that the supra-
show an increase of pathologic signals sugges- scapular nerve was involved in 97% of the sub-
tive of muscular denervation [95]. jects and the axillary nerve in 50% [80].
14.3.5.4 Polyneuropathies Imaging Findings

(Parsonage-Turner There is no specific test for the diagnosis of
Syndrome) Parsonage-Turner syndrome. EMG, nerve con-
Parsonage-Turner syndrome is an uncommon, duction studies, and MRI must be interpreted in
self-limiting disorder characterized by immedi- light of the patient’s clinical history. MRI is the
ate onset of nontraumatic shoulder pain accom- modality of choice in patients with shoulder pain
panied with progressive weakness of the shoulder and weakness, being sensitive for changes indi-
girdle musculature. It was first recognized in 48 cating denervation injury. The studies by Gaskin
patients by Spillane in 1943 [97] and then by and Helms [110] and Scalf et al. [104] are the
a b
Fig. 14.12 37-Year old male sagittal T2-weighted fat- history of trauma or other pathology and no evidence of
suppressed coronal (a) and sagittal (b) oblique showing compressive lesions in the suprascapular notch or rotator
diffuse neurogenic edema of supraspinatus (arrow) and cuff tear (not shown)
infraspinatus (curved arrow) muscles. The patient had no
largest reported series describing the MRI fea- peripheral nerves and other causes of intramus-
tures of Parsonage-Turner syndrome to date. The cular high signal including myositis, rhabdomy-
diagnosis is proposed when there is an abnormal- olysis, inflammatory myopathies, compartment
ity of muscles innervated by the brachial plexus syndrome, and tumor involvement of muscle
in the absence of history of excessive overhead [112, 113].
activity, trauma, or morphologic cause at
MRI. The earliest recognizable change in dener-
vated muscles is diffusely high signal on fluid- References
sensitive sequences such as STIR or T2-weighted
1. Kamath S, Venkatanarasimha N, Walsh M, Hughes
images (because of increase in extracellular water P. MRI appearance of muscle denervation. Skelet
content) and normal signal on T1-weighted Radiol. 2008;37:397–404.
sequences [1]. After a few weeks in the subacute 2. Blum A, Lecocq S, Louis M, Wassel J, Moisei A,
to chronic phase, the denervated muscle may Teixeira P. The nerves around the shoulder. Eur J
Radiol. 2013;82:2–16.
decrease in volume with increased T1 signal 3. Boykin RE, Friedman DJ, Higgins LD, Warner
because of fatty infiltration (Fig. 14.12) [104]. JJ. Suprascapular neuropathy. J Am Acad Orthop
Intramuscular signal may return to normal s everal Surg. 2010;92:2348–64.
months after the chronic phase; however, in com- 4. Lorei MP, Hershman EB. Peripheral nerve injuries in
athletes. Sports Med. 1993;16:130–47.
plete muscle denervation (>1 year after injury), 5. Ludig T, Walter F, Chapuis D, Molé D, Roland J,
changes are irreversible [111]. Blum A. MR imaging evaluation of suprascapular
MRI is also helpful in excluding intrinsic nerve entrapment. Eur Radiol. 2001;11:2161–9.
shoulder abnormalities that can create symptoms 6. Bencardino JT, Rosenberg ZS. Entrapment neuropa-
thies of the shoulder and elbow in the athlete. Clin
equivalent to Parsonage-Turner syndrome such Sports Med. 2006;25:465–87.
as rotator cuff tears, impingement syndrome, and 7. Aiello I, Serra G, Traina G, Tugnoli V. Entrapment
labral tears. MRI can display structural lesions of the suprascapular nerve at the spinoglenoid notch.
that may produce similar denervation changes in Ann Neurol. 1982;12:314–6.
8. Bigliani LU, Dalsey RM, McCann PD, April
the rotator cuff musculature such as cuff tears or EW. An anatomical study of the suprascapular
masses compressing the brachial plexus or nerve. Arthroscopy. 1990;6:301–5.
9. Warner J, Krushell R, Masquelet A, Gerber of the shoulder. Magn Reson Imaging Clin N Am.
C. Anatomy and relationships of the suprascapular 2012;20:373–91.
nerve. J Bone Joint Surg Am. 1992;74:36–45. 28. Bianchi S, Martinoli C. Shoulder. In: Anonymous
10. Brown D, James D, Roy S. Pain relief by suprascap- ultrasound of the musculoskeletal system. Berlin:
ular nerve block in gleno-humeral arthritis. Scand J Springer; 2007. p. 189–331.
Rheumatol. 1988;17:411–5. 29. Canella C, Demondion X, Abreu E, Marchiori E,
11. Matsumoto D, Suenaga N, Oizumi N, Hisada Y, Cotten H, Cotten A. Anatomical study of spinal
Minami A. A new nerve block procedure for the accessory nerve using ultrasonography. Eur J Radiol.
suprascapular nerve based on a cadaveric study. J 2013;82:56–61.
Shoulder Elb Surg. 2009;18:607–11. 30. Kim S, Hong SH, Jun WS, et al. MR imaging map-
12. Ritchie ED, Tong D, Chung F, Norris AM, Miniaci ping of skeletal muscle denervation in entrapment
A, Vairavanathan SD. Suprascapular nerve block and compressive neuropathies. Radiographics.
for postoperative pain relief in arthroscopic shoul- 2011;31:319–32.
der surgery: a new modality? Anesth Analg. 31. Beltran J, Rosenberg ZS. Diagnosis of compressive
1997;84:1306–12. and entrapment neuropathies of the upper extrem-
13. Tubbs RS, Tyler-Kabara EC, Aikens AC, et al. ity: value of MR imaging. AJR Am J Roentgenol.
Surgical anatomy of the axillary nerve within the 1994;163:525–31.
quadrangular space. J Neurosurg. 2005;102:912–4. 32. Petchprapa CN, Rosenberg ZS, Sconfienza LM,
14. Apaydin N, Tubbs RS, Loukas M, Duparc F. Review Cavalcanti CFA, La Rocca Vieira R, Zember
of the surgical anatomy of the axillary nerve and the JS. MR imaging of entrapment neuropathies of
anatomic basis of its iatrogenic and traumatic injury. the lower extremity: part 1. The pelvis and hip 1.
Surg Radiol Anat. 2010;32:193–201. Radiographics. 2010;30:983–1000.
15. McClelland D, Paxinos A. The anatomy of the quad- 33. Yamabe E, Nakamura T, Oshio K, Kikuchi Y,
rilateral space with reference to quadrilateral space Ikegami H, Toyama Y. Peripheral nerve injury:
syndrome. J Shoulder Elb Surg. 2008;17:162–4. diagnosis with MR imaging of denervated skeletal
16. Safran MR. Nerve injury about the shoulder in ath- muscle—experimental study in rats 1. Radiology.
letes, part 2: long thoracic nerve, spinal accessory 2008;247:409–17.
nerve, burners/stingers, thoracic outlet syndrome. 34. Goutallier D, Postel JM, Bernageau J, Lavau L,
Am J Sports Med. 2004;32:1063–76. Voisin MC. Fatty infiltration of disrupted rota-
17. Wiater JM, Bigliani LU. Spinal accessory nerve tor cuff muscles. Rev Rhum Engl Ed. 1995;62:
injury. Clin Orthop. 1999;368:5–16. 415–22.
18. Pecina M, Krmpotic-Nemanic J, Markiewitz 35. Ferretti A, Cerullo G, RUsso G. Suprascapular neu-
A. Tunnel syndromes in the upper extremities; 1991. ropathy in volleyball players. J Bone Joint Surg Am.
p. 11–84. 1987;69:260–3.
19. Ho E, Cofield RH, Balm MR, Hattrup SJ, Rowland 36. Holzgraefe M, Kukowski B, Eggert S. Prevalence
CM. Neurologic complications of surgery for of latent and manifest suprascapular neuropathy in
anterior shoulder instability. J Shoulder Elb Surg. high-performance volleyball players. Br J Sports
1999;8:266–70. Med. 1994;28:177–9.
20. Lynch NM, Cofield RH, Silbert PL, Hermann 37. Ringel SP, Treihaft M, Carry M, Fisher R, Jacobs
RC. Neurologic complications after total shoulder P. Suprascapular neuropathy in pitchers. Am J Sports
arthroplasty. J Shoulder Elb Surg. 1996;5:53–61. Med. 1990;18:80–6.
21. Small NC. Complications in arthroscopic sur- 38. Witvrouw E, Cools A, Lysens R, et al. Suprascapular
gery performed by experienced arthroscopists. neuropathy in volleyball players. Br J Sports Med.
Arthroscopy. 1988;4:215–21. 2000;34:174–80.
22. Rodeo SA, Forster RA, Weiland AJ. Neurological 39. Lee BC, Yegappan M, Thiagarajan P. Suprascapular
complications due to arthroscopy. J Bone Joint Surg nerve neuropathy secondary to spinoglenoid notch
Am. 1993;75:917–26. ganglion cyst: case reports and review of literature.
23. Segmüller HE, Alfred SP, Zilio G, Saies AD, Hayes Ann Acad Med Singap. 2007;36:1032.
MG. Cutaneous nerve lesions of the shoulder and 40. Semmler A, von Falkenhausen M, Schroder
arm after arthroscopic shoulder surgery. J Shoulder R. Suprascapular nerve entrapment by a spinogle-
Elb Surg. 1995;4:254–8. noid cyst. Neurology. 2008;70:890.
24. Boardman ND, Cofield RH. Neurologic com- 41. Yi JW, Cho NS, Rhee YG. Intraosseous ganglion
plications of shoulder surgery. Clin Orthop. of the glenoid causing suprascapular nerve entrap-
1999;368:44–53. ment syndrome: a case report. J Shoulder Elb Surg.
25. Marecek GS, Saltzman MD. Complications in 2009;18:e25–7.
shoulder arthroscopy. Orthopedics. 2010;33:492. 42. Solheim LF, Roaas A. Compression of the supra-
26. Piasecki DP, Romeo AA, Bach BR Jr, Nicholson scapular nerve after fracture of the scapular notch.
GP. Suprascapular neuropathy. J Am Acad Orthop Acta Orthop Scand. 1978;49:338–40.
Surg. 2009;17:665–76. 43. Travlos J, Goldberg I, Boome RS. Brachial plexus
27. Budzik J, Wavreille G, Pansini V, Moraux A, lesions associated with dislocated shoulders. J Bone
Demondion X, Cotten A. Entrapment neuropathies Joint Surg Br. 1990;72:68–71.
44. Visser C, Coene L, Brand R, Tavy D. The incidence logic findings and clinical significance. Radiology.
of nerve injury in anterior dislocation of the shoulder 1994;190:653–8.
and its influence on functional recovery a prospec- 59. Westerheide KJ, Dopirak RM, Karzel RP, Snyder
tive clinical and EMG study. J Bone Joint Surg Br. SJ. Suprascapular nerve palsy secondary to spino-
1999;81:679–85. glenoid cysts: results of arthroscopic treatment.
45. Yoon TN, Grabois M, Guillen M. Suprascapular Arthroscopy. 2006;22:721–7.
nerve injury following trauma to the shoulder. J 60. Tung GA, Entzian D, Stern JB, Green A. MR imag-
Trauma. 1981;21:652–5. ing and MR arthrography of paraglenoid labral
46. Mallon WJ, Wilson RJ, Basamania CJ. The associa- cysts. Am J Roentgenol. 2000;174:1707–15.
tion of suprascapular neuropathy with massive rota- 61. O'Connor EE, Dixon LB, Peabody T, Stacy GS. MRI
tor cuff tears: a preliminary report. J Shoulder Elb of cystic and soft-tissue masses of the shoulder joint.
Surg. 2006;15:395–8. Am J Roentgenol. 2004;183:39–47.
47. Lajtai G, Pfirrmann CW, Aitzetmuller G, Pirkl 62. Van Es H. MRI of the brachial plexus. Eur Radiol.
C, Gerber C, Jost B. The shoulders of profes- 2001;11:325–36.
sional beach volleyball players: high prevalence of 63. Martinoli C, Bianchi S, Pugliese F, et al. Sonography
infraspinatus muscle atrophy. Am J Sports Med. of entrapment neuropathies in the upper limb (wrist
2009;37:1375–83. excluded). J Clin Ultrasound. 2004;32:438–50.
48. Cummins CA, Anderson K, Bowen M, Nuber G, 64. Martinoli C, Gandolfo N, Perez MM, et al. Brachial
Roth SI. Anatomy and histological characteristics of plexus and nerves about the shoulder. Semin
the spinoglenoid ligament. J Bone Joint Surg Am. Musculoskelet Radiol. 2010;14:523.
1998;80:1622–5. 65. Huang K, Tu Y, Huang T, Hsu RW. Suprascapular
49. Plancher KD, Luke TA, Peterson RK, Yacoubian neuropathy complicating a Neer type I distal cla-
SV. Posterior shoulder pain: a dynamic study vicular fracture: a case report. J Orthop Trauma.
of the spinoglenoid ligament and treatment 2005;19:343–5.
with arthroscopic release of the scapular tunnel. 66. Visser CP, Coene L, Brand R, Tavy DL. Nerve
Arthroscopy. 2007;23:991–8. lesions in proximal humeral fractures. J Shoulder
50. Demirhan M, Imhoff AB, Debski RE, Patel PR, Fu Elb Surg. 2001;10:421–7.
FH, Woo SL. The spinoglenoid ligament and its rela- 67. Wijdicks CA, Armitage BM, Anavian J, Schroder
tionship to the suprascapular nerve. J Shoulder Elb LK, Cole PA. Vulnerable neurovasculature with a
Surg. 1998;7:238–43. posterior approach to the scapula. Clin Orthop Relat
51. Bayramoğlu A, Demiryürek D, Tüccar E, et al. Res. 2009;467:2011–7.
Variations in anatomy at the suprascapular notch 68. Fritz RC, Helms CA, Steinbach LS, Genant
possibly causing suprascapular nerve entrapment: HK. Suprascapular nerve entrapment: evaluation
an anatomical study. Knee Surg Sports Traumatol with MR imaging. Radiology. 1992;182:437–44.
Arthrosc. 2003;11:393–8. 69. Bredella M, Tirman P, Fritz R, Wischer T, Stork A,
52. Cummins CA, Messer TM, Nuber GW. Current Genant H. Denervation syndromes of the shoulder
concepts review-suprascapular nerve entrapment*. J girdle: MR imaging with electrophysiologic correla-
Bone Joint Surg. 2000;82:415–24. tion. Skelet Radiol. 1999;28:567–72.
53. Rengachary SS, Neff JP, Singer PA, Brackett 70. Cahill BR, Palmer RE. Quadrilateral space syn-
CE. Suprascapular entrapment neuropathy: a clini- drome. J Hand Surg. 1983;8:65–9.
cal, anatomical, and comparative study: part 1: clini- 71. Sanders TG, Tirman PF. Paralabral cyst: an unusual
cal study. Neurosurgery. 1979;5:441–6. cause of quadrilateral space syndrome. Arthroscopy.
54. Ticker JB, Djurasovic M, Strauch RJ, et al. The inci- 1999;15:632–7.
dence of ganglion cysts and other variations in anat- 72. Redler MR, Ruland LJ 3rd, FC MC 3rd. Quadrilateral
omy along the course of the suprascapular nerve. J space syndrome in a throwing athlete. Am J Sports
Shoulder Elb Surg. 1998;7:472–8. Med. 1986;14:511–3.
55. Abboud JA, Silverberg D, Glaser DL, Ramsey 73. Schulte KR, Warner JJ. Uncommon causes of shoul-
ML, Williams GR. Arthroscopy effectively treats der pain in the athlete. Orthop Clin North Am.
ganglion cysts of the shoulder. Clin Orthop. 1995;26:505–28.
2006;444:129–33. 74. Robinson P, White L, Lax M, Salonen D, Bell
56. Fehrman DA, Orwin JF, Jennings RM. Suprascapular R. Quadrilateral space syndrome caused by glenoid
nerve entrapment by ganglion cysts: a report of six labral cyst. Am J Roentgenol. 2000;175:1103–5.
cases with arthroscopic findings and review of the 75. Tirman PF, Bost FW, Steinbach LS, et al. MR
literature. Arthroscopy. 1995;11:727–34. arthrographic depiction of tears of the rotator cuff:
57. Moore TP, Fritts HM, Quick DC, Buss benefit of abduction and external rotation of the arm.
DD. Suprascapular nerve entrapment caused by Radiology. 1994;192:851–6.
supraglenoid cyst compression. J Shoulder Elb Surg. 76. Sofka CM, Lin J, Feinberg J, Potter HG. Teres minor
1997;6:455–62. denervation on routine magnetic resonance imaging
58. Tirman PF, Feller JF, Janzen DL, Peterfy CG, of the shoulder. Skelet Radiol. 2004;33:514–8.
Bergman AG. Association of glenoid labral cysts 77. Perlmutter GS. Axillary nerve injury. Clin Orthop.
with labral tears and glenohumeral instability: radio- 1999;368:28–36.
78. Bryan WJ, Schauder K, Tullos HS. The axil- 95. Akgun K, Aktas I, Terzi Y. Winged scapula caused
lary nerve and its relationship to common sports by a dorsal scapular nerve lesion: a case report. Arch
medicine shoulder procedures. Am J Sports Med. Phys Med Rehabil. 2008;89:2017–20.
1986;14:113–6. 96. Kuhn JE, Plancher KD, Hawkins RJ. Scapular
79. Wilson L, Sundaram M, Piraino DW, Ilaslan H, Winging. J Am Acad Orthop Surg. 1995;3:319–25.
Recht MP. Isolated teres minor atrophy: manifes- 97. Spillane J. Localised neuritis of the shoulder
tation of quadrilateral space syndrome or traction girdle: a report of 46 cases in the MEF. Lancet.
injury to the axillary nerve? Orthopedics. 2006;29: 1943;242:532–5.
447–50. 98. Parsonage M, Aldren Turner J. Neuralgic amy-
80. Yanny S, Toms AP. MR patterns of denerva- otrophy the shoulder-girdle syndrome. Lancet.
tion around the shoulder. Am J Roentgenol. 1948;251:973–8.
2010;195:W157–63. 99. Tsairis P, Dyck PJ, Mulder DW. Natural history of
81. Cothran RL Jr, Helms C. Quadrilateral space syn- brachial plexus neuropathy: report on 99 patients.
drome: incidence of imaging findings in a population Arch Neurol. 1972;27:109–17.
referred for MRI of the shoulder. Am J Roentgenol. 100. Turner JA. Acute brachial radiculitis. Br Med J.
2005;184:989–92. 1944;2:592–4.
82. Tuckman GA, Devlin TC. Axillary nerve injury 101. Dixon GJ, Dick T. Acute brachial radiculitis course
after anterior glenohumeral dislocation: MR find- and prognosis. Lancet. 1945;246:707–8.
ings in three patients. AJR Am J Roentgenol. 102. Magee KR, DeJong RN. Paralytic brachial neuri-
1996;167:695–7. tis: discussion of clinical features with review of 23
83. Price MR, Tillett ED, Acland RD, Nettleton cases. JAMA. 1960;174:1258–62.
GS. Determining the relationship of the axil- 103. Weikers NJ, Mattson RH. Acute paralytic brachial
lary nerve to the shoulder joint capsule from an neuritis. A clinical and electrodiagnostic study.
arthroscopic perspective. J Bone Joint Surg Am. Neurology. 1969;19:1153–8.
2004;86:2135–42. 104. Scalf RE, Wenger DE, Frick MA, Mandrekar JN,
84. Fleckenstein JL, Watumull D, Conner KE, et al. Adkins MC. MRI findings of 26 patients with
Denervated human skeletal muscle: MR imaging Parsonage-Turner syndrome. Am J Roentgenol.
evaluation. Radiology. 1993;187:213–8. 2007;189:W39–44.
85. Bencardino J, Petchprapa C, Rybak L, Hassankhani 105. Pellas F, Olivares J, Zandotti C, Delarque
A, Palmer W. Teres minor atrophy: a sign of axil- A. Neuralgic amyotrophy after parvovirus B19
lary denervation injury following shoulder trauma. infection. Lancet. 1993;342:503–4.
Radiology. 2002;225:371. 106. Suarez GA, Giannini C, Bosch EP, et al. Immune
86. Omar N, Alvi F, Srinivasan M. An unusual presen- brachial plexus neuropathy: suggestive evidence for
tation of whiplash injury: long thoracic and spi- an inflammatory-immune pathogenesis. Neurology.
nal accessory nerve injury. Eur Spine J. 2007;16: 1996;46:559–61.
275–7. 107. Ryan M, Twair A, Nelson E, Brennan D, Eustace
87. McFarland EG, Garzon-Muvdi J, Jia X, Desai P, S. Whole body magnetic resonance imaging in
Petersen SA. Clinical and diagnostic tests for shoul- the diagnosis of Parsonage Turner syndrome. Acta
der disorders: a critical review. Br J Sports Med. Radiol. 2004;45:534–9.
2010;44:328–32. 108. Beghi E, Kurland LT, Mulder DW, Nicolosi A. Brachial
88. Wiater JM, Flatow EL. Long thoracic nerve injury. plexus neuropathy in the population of Rochester,
Clin Orthop. 1999;368:17–27. Minnesota, 1970–1981. Ann Neurol. 1985;18:320–3.
89. Sahin F, Yilmaz F, Esit N, Aysal F, Kuran 109. Helms CA, Martinez S, Speer KP. Acute brachial
B. Compressive neuropathy of long thoracic nerve neuritis (Parsonage-Turner syndrome): MR imag-
and accessory nerve secondary to heavy load bearing appearance--report of three cases. Radiology.
ing. Eura Medicophys. 2007;47:71–4. 1998;207:255–9.
90. O'Dell M, Stubblefield M, O'Dell M, Stubblefield 110. Gaskin CM, Helms CA. Parsonage-Turner
M. Cancer rehabilitation: principles and practice. Syndrome: MR Imaging Findings and Clinical
New York: Demos Medical Publishing; 2009. Information of 27 Patients 1. Radiology.
91. Martin RM, Fish DE. Scapular winging: anatomi- 2006;240:501–7.
cal review, diagnosis, and treatments. Curr Rev 111. Sallomi D, Janzen DL, Munk PL, Connell DG,
Musculoskelet Med. 2008;1:1–11. Tirman PF. Muscle denervation patterns in upper limb
92. Toth C, McNeil S, Feasby T. Peripheral nervous nerve injuries: MR imaging findings and anatomic
system injuries in sport and recreation. Sports Med. basis. AJR Am J Roentgenol. 1998;171:779–84.
2005;35:717–38. 112. Uetani M, Hayashi K, Matsunaga N, Imamura K, Ito
93. Tubbs RS, Tyler-Kabara EC, Aikens AC, et al. N. Denervated skeletal muscle: MR imaging. Work
Surgical anatomy of the dorsal scapular nerve. J in progress. Radiology. 1993;189:511–5.
Neurosurg. 2005;102:910–1. 113. May DA, Disler DG, Jones EA, Balkissoon AA,
94. Chen D, Gu Y, Lao J, Chen L. Dorsal scapular nerve Manaster B. Abnormal signal intensity in skeletal
compression. Atypical thoracic outlet syndrome. muscle at MR imaging: patterns, pearls, and pitfalls
Chin Med J. 1995;108:582–5. 1. Radiographics. 2000;20:S295–315.

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The Shoulder

ISBN 978-3-030-06239-2 ISBN 978-3-030-06240-8 (eBook)

© Springer Nature Switzerland AG 2019

Part I Imaging Techniques

1 Current Protocols for Radiographic and CT

Part II Rotator Cuff, Biceps and Rotator Interval

5 Imaging Diagnosis of Rotator Cuff Pathology

Part III The Labrum

7 Imaging Diagnosis of Glenohumeral Instability

Part IV Trauma and Arthropathies

9 Imaging Diagnosis of Shoulder Girdle Fractures ������������������������ 191

12 Imaging Diagnosis of Tumors and Tumorlike

Ronald S. Adler Department of Radiology, New York University Langone

Mingqian Huang Department of Radiology, Stony Brook University

Eric A. Walker Department of Radiology, Milton S. Hershey Medical

© Springer Nature Switzerland AG 2019 3

Image Analysis and Clinical Benefit 1.2.1.3 Axillary View

Radiographic Beam: (c) Radiographic beam angled 25° upwards

Table 1.1 Rockwood classification of ACJ injuries [11]

1.2.2 Specialized Radiographic Image Analysis and Clinical Benefit

Radiographic Beam: 1.2.2.3 West Point view

anterior glenoid rim fractures with 70% sensitiv- Radiographic Beam:

Technique (Fig. 1.8a) Image Interpretation and Clinical Benefit

Other specialized view: 1.3.1 CT Technique (64-Slice

compared to radiographs allowing more accurate osteoarthritic shoulder, as well as estimation of

Fig. 1.14 2D double-oblique reconstruction en face to

the information from the contralateral normal

Seema Meraj and Jenny T. Bencardino

Magnetic resonance (MR) is the imaging modality

2.1 Conventional MR Protocol

© Springer Nature Switzerland AG 2019 23

diagnostic confidence in the evaluation of the 2.2  ormal MR Appearance

The glenoid labrum rims the glenoid fossa and is

within the labral substance extending to the sur- 2.3 Artifacts/Pitfalls

p­ articularly of the supraspinatus on the coronal 2.3.1 Vacuum Phenomenon

2.3.2 Chemical Shift Artifact

In addition to the previously described magic

Table 2.2 Protocol for direct MR arthrography of the shoulder

echo sequences are performed following nor-

Waldt and colleagues demonstrated a sensitiv- ­ embrane permeability, and presence/absence

2.4.2 Indirect MRA 2.4.2.1 Imaging Technique

Table 2.3 Protocol for indirect MR arthrography of the shoulder

ues seen for full-thickness supraspinatus tears

2.4.2.2 Advantages and Disadvantages

Direct MR arthrography has shown 100% sen-

2.5.1.3 Indirect MR Arthrography

2.6 Biochemical Imaging methods for detecting early changes in articular

3.1 Introduction i­mpingement syndromes [4]. In addition to gray-

© Springer Nature Switzerland AG 2019 55

tendon is positioned inferior to the infraspina-

Fig. 3.5 Tendon orientation—long-axis (a) and short-axis (b) views

Fig. 3.6 Rocking the transducer to eliminate anisotropic effect at footprint

Table 3.1 Standardized shoulder sonography protocol

3.5 Technique Table 3.2 Biceps tendon guidelines

Start by palpating the acromioclavicular joint and

Table 3.4 Supraspinatus and infraspinatus tendon imaging

3.6.5  tep 5: Muscle Evaluation—

4.1 Introduction available, especially in teenagers and young

Image-guided shoulder interventions are most 4.2.2 Procedure

Part I Imaging Techniques

1 Current Protocols for Radiographic and CT

Part II Rotator Cuff, Biceps and Rotator Interval

5 Imaging Diagnosis of Rotator Cuff Pathology

Part III The Labrum

7 Imaging Diagnosis of Glenohumeral Instability

Part IV Trauma and Arthropathies

9 Imaging Diagnosis of Shoulder Girdle Fractures �� 191

12 Imaging Diagnosis of Tumors and Tumorlike

Image Analysis and Clinical Benefit 1.2.1.3 Axillary View

1.2.2 Specialized Radiographic Image Analysis and Clinical Benefit

Radiographic Beam: 1.2.2.3 West Point view

Other specialized view: 1.3.1 CT Technique (64-Slice

2.1 Conventional MR Protocol

diagnostic confidence in the evaluation of the 2.2 ormal MR Appearance

within the labral substance extending to the sur- 2.3 Artifacts/Pitfalls

p articularly of the supraspinatus on the coronal 2.3.1 Vacuum Phenomenon

2.3.2 Chemical Shift Artifact

Waldt and colleagues demonstrated a sensitiv- embrane permeability, and presence/absence

2.4.2 Indirect MRA 2.4.2.1 Imaging Technique

2.4.2.2 Advantages and Disadvantages

2.5.1.3 Indirect MR Arthrography

2.6 Biochemical Imaging methods for detecting early changes in articular

3.1 Introduction impingement syndromes [4]. In addition to gray-

3.5 Technique Table 3.2 Biceps tendon guidelines

3.6.5 tep 5: Muscle Evaluation—

4.1 Introduction available, especially in teenagers and young

Image-guided shoulder interventions are most 4.2.2 Procedure

4.3.2 Fluoroscopy may be used to assure proper arm positioning

4.6 Biceps Tendon Sheath

anubrium or clavicular head as a backstop for

4.11 Ganglion/Paralabral Cyst

5.1 Introduction anatomic variables external to the tendon, such as

the infraspinatus and teres minor muscles can be 5.2.4 Subscapularis

5.3 Pathologic Conditions firmed in patients at surgery or on imaging, which

5.4 Postoperative Imaging thickness tendon tears can be repaired through an

6.1 Introduction of the subscapularis tendon inferiorly, and the

6.3.1 Biceps Tendon Pathology 6.3.2 Biceps Reflection Pulley Injury

more anterior extra-articular course depending 6.3.3 otator Interval Laxity

6.5 Conclusion imaging in assisting the clinician to make the

7.5.3 Capsulolabral Complex A GLAD lesion (Fig. 7.5) represents an ante-

7.6 Summary involved in glenohumeral instability with an

8.1 Normal Labrum surface area of the glenoid by approximately one-

8.1.2.4 Bicipital Labral Sulcus

8.1.2.6 Sublabral Foramen

8.2 Microinstability The performance of an elite throwing athlete,

9.1 Introduction vascular structures, and fluid collections that may

9.2.2.3 Ultrasound Findings

9.2.2.4 MR Findings 9.2.3 Postoperative Imaging

9.3.2 Sternoclavicular Joint Injuries

9.3.2.4 MR Findings clavicle containing a variably developed intra-

9.4 Acromioclavicular Joint 9.4.2 Acromioclavicular Joint

9.4.2.2 Radiographic and CT Findings

9.5 Scapula of an apophysis (which generally occurs by

9.5.2.3 Ultrasound Findings

9.5.2.4 MR Findings

9.5.3 Postoperative Imaging