Rotator Cuff Injury Holistic Treatments
One approach to evaluating the rotator cuff on MRI is to begin by reviewing the coronal oblique PD images to get an overview of the anatomy (Fig. 1). Proton density images are weighted intermediately between T1 and T2 signal. They provide superior signal-to-noise ratio and spatial resolution, albeit at the expense of soft tissue contrast. Large cuff tears and distortions of the anatomy may be identified. Shoulder alignment may be evaluated also. Occasionally because of improper positioning or patient motion the shoulder is imaged in internal rotation. This imaging leads to overlap of the supraspina-tus and infraspinatus tendons on coronal oblique images 5 . The coronal oblique plane usually is the most useful plane for cuff evaluation because it parallels the course of the most commonly torn cuff tendons, the supraspinatus and infraspinatus 6 . The subscapularis often is seen well in the coronal oblique plane but is evaluated best on axial images. The teres minor tendon is seen best...
Intermediate or inhomogeneous signal in the cuff tendons are causes of diagnostic difficulty. Although the signal may be because of tendinopathy or partial tearing, artifacts such as magic angle phenomenon, inhomogeneous fat suppression, and partial volume averaging also may cause an increase in signal. Magic angle phenomenon occurs on short TE sequences, such as PD sequences. Artifactually increased signal may be seen where the fibers of the cuff tendons are aligned at a 55-degree angle to the main magnetic field. At that angle there is T2 lengthening that results in focally increased signal. This artifact is recognized by its characteristic location where the tendon begins to slope downwards. The artifact is confirmed by comparison to T2 images that have a long TE and so do not show the artifact 1 .
The spectrum of rotator cuff pathology ranges from tendinopathy and fraying to partial- or full-thickness tearing. Partial-thickness tears may be classified further as occurring on the articular or bursal surface of the tendon. A third type of partial-thickness tear is the intrasubstance tear, which occurs within the substance of the tendon without extending to the tendon surface. This type of tear is uncommon but is important to identify on MRI because the tendon surface may appear normal at arthroscopy and the tear may be missed. The most specific sign of a cuff tear is discontinuity of the cuff fibers with fluid signal in the intervening gap (Figs. 3 and 4). Unfortunately, this gap may only be seen in fairly large tears that measure more than several millimeters. For smaller tears the signal on T2-weighted imaging and secondary signs of cuff tearing should be considered carefully. Secondary signs include fluid in the subacromial or subdeltoid bursa, tendon retraction, and muscular...
The most common concern in the patient who has postoperative pain is retear of the rotator cuff repair. The patient usually presents with a known incident and details a history of acute pain associated with loss of motion. The diagnostic criteria are similar to the preoperative evaluation with the presence of fluid signal on a T2-weighted image that extends through the entire tendon substance. In the case of MR arthrography, simply seeing the contrast extend into the subacromial-subdeltoid space is not enough to diagnose a retear. The normal postoperative shoulder does not need to be watertight, so a small amount of leakage can be expected (Fig. 1). The presence of a definite gap in the tendon makes the diagnosis more substantial (Fig. 2). Fig. 1. Intact rotator cuff repair with small amount of leakage. (A) T1 fat-suppressed axial with contrast seen in the subdeltoid space (arrow). (B) T1 fat-suppressed coronal oblique with contrast seen in the subdeltoid space. The rotator cuff...
The clinical symptoms and signs of Parsonage-Turner syndrome can mimic a wide range of disease entities, such as rotator cuff disease, cervical radiculop-athy, spinal cord tumor, and peripheral nerve compression. Differentiation of the entity from compressive neuropathy of the suprascapular nerve can be particularly confusing. Useful features in distinguishing Parsonage-Turner syndrome from suprascapular nerve entrapment include the more insidious onset of pain and lack of spontaneous resolution of symptoms noted in the latter entity. MRI detection of paralabral ganglions or other impinging mass lesions within the suprascapular notch is also supportive of suprascapular nerve entrapment 34 . MRI can also be useful in excluding other disease entities such as rotator cuff tear, which can clinically mimic Parsonage-Turner syndrome.
The fibrous structures in the shoulder are highly organized tissues with normally low signal on all pulse sequences. These structures include the joint capsule, glenohumeral ligaments, rotator cuff tendons, and the labrum. When there is disruption of the organization structure because of tendinopathy or tear, the signal intensity increases. Unfortunately, there are confounding factors that may cause artifactually increased signal intensity in the absence of pathology. These are discussed in more depth elsewhere in this article.
During the deceleration phase, after ball release, there is strong eccentric contraction of all muscle groups to maintain the humerus within the glenoid fossa. Joint loads and compressive forces can be large enough to cause rotator cuff tears 43 . These compressive forces, combined with internal rotation and anterior displacement of the humerus, can also cause grinding of the humeral head on the biceps tendon and anterosuperior aspect of the labrum and lead
MRI provides excellent soft tissue contrast and allows for multiplanar imaging in anatomic planes. Because of these advantages MRI has become the study of choice for imaging of shoulder pathology. Some structures, such as the rotator cuff, humeral head contour, and glenoid shape, are evaluated well with conventional MRI. When more sensitive evaluation of the labrum, capsule, articular cartilage, and glenohumeral ligaments is required or when a partial-thickness rotator cuff tear is suspected, magnetic resonance (MR) arthrography with intra-articular contrast can be performed. For MR arthrography contrast is injected directly into the glenohumeral joint. This article reviews the appearances of normal anatomic structures in MRI of the shoulder and disorders involving the rotator cuff and glenoid labrum.
The shoulder is composed of two articulations the glenohumeral joint and the acromioclavicular (AC) joint 2 . Glenohumeral articulation is maintained by the joint capsule, glenohumeral ligaments, rotator cuff musculature, and labrum. The labrum is a ring of fibrocartilage that is adherent to the glenoid rim. The intact labrum increases the concavity of the bony glenoid and the superior labrum serves as the anchor for the long head of the biceps tendon. The joint capsule may insert variably on the periphery of the labrum or on the neck of the scapula 3 . Distally, the capsule inserts on the anatomic neck of the humerus. The rotator cuff is comprised of tendons from the supraspinatus, infraspina-tus, teres minor, and subscapularis muscles. The supraspinatus, infraspinatus, and teres minor muscles arise from the posterior surface of the scapula, cross posterior to the humeral head, and insert on the greater tuberosity. The supra-spinatus insertion is most superior and the teres minor...
8 Tirman PF, Bost FW, Steinbach LS, et al. MR arthrographic depiction of tears of the rotator cuff benefit of abduction and external rotation of the arm. Radiology 1994 192(3) 851-5. 11 Lee SY, LeeJK. Horizontal component of partial thickness tears of rotator cuff imaging characteristics and comparison of ABER view with oblique coronal view at MR arthrography initial results. Radiology 2002 224 470-6. Meister K, Buckley B, Batts J. The posterior impingement sign diagnosis of rotator cuff and Morgan CD, Burkhart SS, Palmeri M, etal. Type II SLAP lesions three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998 14 553-65. Legan JM, Burkhart TK, Goff WB II, et al. Tears of the glenoid labrum MR imaging of 88 arthroscopically confirmed cases. Radiology 1991 179 241-6. Ferrari JD, Ferrari DA, Coumas J, et al. Posterior ossification of the shoulder the Bennett lesion. Etiology, diagnosis and treatment. Am J Sports Med 1994 22 171-5. Blevins FT....
Triplanar T1 sequences with or without fat suppression are obtained to take advantage of the contrast provided by the injected solution. A T2-weighted sequence is performed to evaluate the extra-articular structures for pathology, such as bursal surface partial-thickness rotator cuff tear, soft tissue mass, and bone marrow abnormality.
Conventional MRI, supplemented with MR arthrography, can accurately diagnose injuries sustained by the throwing athlete, such as rotator cuff tears and tendinosis, as well as labral and capsuloligamentous pathologic conditions 2-4 . MR arthrography requires the intra-articular injection of 12 mL or more of a dilute gadolinium solution (1 250 or 2 mmol L) to distend the joint capsule and outline the labral and articular surface tears of the rotator cuff 5 . At a concentration of 2 mmol L, the paramagnetic effect of gadolinium and hence its signal intensity on Tl-weighted images in a 1.5 Telsa magnetic field are optimal 6 . Indirect MR arthrography with intravenous administration of gadolinium may also be performed this is dependent on diffusion of contrast into the joint space from the highly vascular synovium. Though it is less invasive than direct MR arthrography, lack of joint distention makes this technique less useful for labral tears 7 .
This depends upon the fracture location relative to muscular insertions. In the more proximal fracture, the rotator cuff abducts and rotates the proximal fragment, while in slightly more distal fractures, pectoralis major serves to adduct. In more distal fractures the deltoid abducts the proximal fragment.
Sonography has become a well-established method for imaging of both the upper and lower extremities however, reports providing surgical confirmation of the accuracy of sonography for upper extremity injuries are limited in number and study size, except for those regarding rotator cuff tears. In contrast, so-nography has been used extensively for many types of soft-tissue injuries in the lower extremity, so there is significant literature confirming the accuracy of so-nography for many types of pathology.
Case Study 20-1 Rotator Cuff Tear After anesthesia induction and positioning in a semisitting (beach chair) position, the surgeon made an anterosuperior deltoid incision (the standard deltopectoral approach) and divided the coracoacro-mial ligament at the acromial attachment. The rotator cuff was identified after the deltoid was retracted and the clavipectoral fascia was incised. The subscapularis tendon was incised proximal to its insertion. After incision of the capsule, inspection showed a large pouch inferiorly in the capsule, consistent with laxity (instability). The torn edges of the capsule were anchored to the rim of the glenoid fossa with heavy nonabsorbable sutures. A flap from the subscapularis tendon was transposed and sutured to the supraspinatus and infraspinatus muscles to bridge the gap. An intraoperative ROM examination showed that the external rotation could be performed past neutral and that the shoulder did not dislocate. The wound was closed, and a shoulder...
The site of pathology is generally found at the origin of the extensor muscle (extensor carpi radialis brevis) at the lateral epicondyle. The period of peak incidence is the fourth decade of life. This finding suggests a degenerative process in the tendon aggravated by repetitive stress, which leads to macroscopic and microscopic tears of the extensor origin. Approximately 40 of these patients will have other sites of soft-tissue degenerative problems (shoulder bursitis, rotator cuff tendinitis).
A complete neurologic examination should be performed. Weakness may be the result of intrinsic shoulder lesions, as in a cuff tear, or of nerve lesions of the brachial plexus or cervical roots. Strength testing at 0 degrees and 90 degrees of elevation is important. Weakness of external rotation with the arm at the side is present with large rotator cuff tears involving the infraspinatus or with C5-6 nerve root problems. The lift-off test for subscapularis tears is performed by placing the back of the hand over L-5 and pushing away from the back. Loss of strength is associated with subscapularis tears.
In examining the shoulder, one should observe the full range of active and passive motion, noting any discrepancy such as that sometimes seen in a rotator cuff tear. Active elevation in the plane of the scapula may demonstrate altered scapular thoracic rhythm with a shrug sign if a rotator cuff tear is present. 3. The impingement sign is positive in patients with rotator cuff inflammation and is noted by flexing the arm forward to the full overhead position. Pain is present during the last 10 degrees of passive elevation. Passive abduction to the 90-degree position with internal rotation will similarly produce pain.
Lateral and axillary views of the scapula are useful in identifying degenerative changes of the glenohumeral joint and calcification of the rotator cuff they are particularly important in the evaluation of acute injuries to the shoulder. V. Common shoulder problems. The most common shoulder problems are impingement syndrome with rotator cuff tears, calcific tendinitis, adhesive capsulitis, acromioclavicular joint pain, thoracic outlet syndrome, and shoulder instability. A. Impingement syndrome generally develops during the fifth decade and may progress to a rotator cuff tear by age 55. The underlying pathology consists of degeneration of the tendons of the rotator cuff. As a result, the insufficient cuff fails to prevent superior migration of the humeral head during elevation. This results in pressure on the rotator cuff and increasing pressure on the bone. Spurs may develop within the coracoacromial ligament over time with cuff degeneration. In some patients, a hooked acromion...
Impingement syndrome, an overuse injury to the rotator cuff, occurs frequently in both male and female patients. However, in women, causative factors are often related to underlying glenohumeral laxity. Increased capsular laxity requires an increase in rotator cuff activity, leading to overuse and impingement. Another factor, especially in the novice female athlete, is deconditioning and weakness of the upper extremity, which leads to rapid fatigue of the rotator cuff, particularly with overhead activity.
The rotator cuff comprises ihe conjoint tendons of supra-spinatus, infraspinatus and teres minor. Infraspinatus and teres minor externally rotate the humerus. Supraspinatus stabilises the head of the humerus in the socket of the glenoid, which allows the deltoid muscle to abduct the arm. The rotator cuff (especially the supraspinatus tendon), the related subacromial bursa and the tendon of the long head of biceps, are the most common sites of pathology in the shoulder.
CT arthrography of the shoulder is an old technique, first developed for the assessment of the glenoid labrum 2 . Following the introduction and eventual widespread use of MRI for shoulder imaging, CTA was for all intents and purposes an antiquated study. Although a noncontrast MRI is excellent for the evaluation of rotator cuff disease, intra-articular pathology such as labral and biceps tendon tears is best evaluated with MRA, which is an invasive examination. As with other joints, a failed MRA can be converted to a CTA if sufficient iodinated contrast media is injected along with the gadolinium contrast agent. Although CTA has not been shown to be superior to MRA in the shoulder, it is CT arthrography of the shoulder can be performed as an air-contrast, double-contrast, or single-contrast examination. Older series of CTA for the evaluation of labral pathology promoted a double-contrast technique. The double-contrast plain film arthrogram is reported to be superior for the...
Anatomy and function The shoulder consists of three joints and two gliding planes, which allow an exceedingly large range of motion at the expense of glenohumeral stability. As a result, the glenohumeral joint is the most commonly dislocated joint in the body. The gliding planes consist of the scapulothoracic surface and the subacromial space. The three joints are the acromioclavicular, sternoclavicular, and glenohumeral articulations. Elevation of the arm is produced by the combined rotation between the scapula and chest wall as well as by the glenohumeral joint. The rotator cuff consists of four muscles the supraspinatus, the infraspinatus, the teres minor, and the subscapularis. In addition to assisting in internal and external rotation, these muscles act as a depressor on the humeral head during shoulder elevation. In this manner, a fulcrum that allows the deltoid to elevate the arm is established. As long as some depressor action of the rotator cuff remains, surprisingly large...
The proximal humerus was divided into four bony parts by Codman - the head, greater tuberosity, lesser tuberosity and shaft. The rotator cuff inserts to the greater (teres minor, supraspinatus and infraspinatus) and lesser (subscapularis) tuberosities. The direction of pull of these muscles determines the displacement of bony fragments after fracture - postero-superiorly for the greater and antero-medially for the lesser tuberosity. The bicipital groove separates the two tuberosities. The pectoralis major muscle inserts to the humeral shaft distal to the surgical neck and displaces the shaft medially. The humeral head lies under the acromial arch and one of the aims of treatment is to maintain enough space under the arch to prevent subsequent impingement.
Evaluation of shoulder pain in RA requires differentiating soft-tissue pain from that of articular origin. Bursitis, bicipital tendinitis, and rotator cuff tears can be discerned with a careful history, examination, diagnostic xylocaine injections, and MRI when indicated (see Chapter.13). Rotator cuff tears are difficult to repair in this group because of degenerated tissue. The presence of severe articular destruction and refractory pain and disability is an indication for total joint replacement. Shoulder prostheses are in a state of evolution, as problems of restoring rotator cuff power in the face of degenerated tissue and loosening of the glenoid component have required design adjustment.
The replacement of the humeral head with a stemmed metallic prosthesis and the glenoid with a polyethylene component provides the arthritic patient with relief of pain and, in many cases, restores a functional range of glenohumeral motion. Postoperative range of motion is largely determined by the preoperative condition of the rotator cuff. Therefore, rheumatoid patients with atrophic cuffs are less likely to gain significant motion than are patients with posttraumatic arthritis or avascular necrosis of the humeral head.
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