Shoulder pathologies

1. SHOULDER PATHOLOGIES CLINICO-RADIOLOGIAL ASSESSMENT DR. Siddharth Gupta

2. ANATOMYJoints (shoulder complex) 3 Bones • Humerus • Scapula • Clavicle 4 Joints • Glenohumeral • Acromioclavicular • Sternoclavicular • Scapulothoracic

3. PARTS OF SYNOVIAL JOINT • Articulating bones • Synovial membrane • Fibrous capsule • Intra-articular structures (like labrum) • Ligaments • Bursae • Muscles

4. BONES

5. LIGAMENTS

7. RADIOGRAPHY • Initial investigation of choice for all shoulder problems. • Can detect most fractures, dislocations, calcific tendinitis and other skeletal causes of pain such as arthritis and bone tumors • Different situations require different types of plain films (AP/Lateral/Axillary views): – Impingement views in clinically suspected impingement syndrome and/or rotator cuff tears to detect subacromial spur – Axial or anterior oblique views in trauma

8. AP VIEW EXTRENAL ROTATION INTERNAL ROTATION

9. RADIOGRAPHIC PROJECTIONS -

10. ULTRASONOGRAPHY Preferred initial modality in suspected rotator cuff pathologies • > 90 % sensitive and specific for rotator cuff tears • Comparable to MRI in evaluation of full thickness rotator cuff tears • Bony pathologies not well seen Advantages –Dynamic evaluation – Guided aspiration / injection possible Disadvantage -Less sensitive partial thickness rotator cuff tears - Cannot accurately evaluate the labral-ligamentous complex.

11. CT SCAN • Superior to plain radiographs in evaluation of complex fractures and fracture-dislocations involving the head of the humerus • Allows planning of treatment of complex proximal humeral fractures MRI • Highly accurate for evaluation of rotator cuff pathologies • Demonstrates other lesions such as ACJ osteoarthritis and avascular necrosis. • Comprehensive display of soft tissue anatomy • Demonstration of the causes for impingement • Useful in characterization and staging of bone tumors

12. MR ARTHROGRAPHY • Most accurate and first line imaging modality for defining: – Rotator cuff pathology – Labral/capsule abnormalities in gleno-humeral instability • Superior depiction of partial-thickness tears compared to conventional MRI. • Disadvantages : invasive, limited availability and high expense. CT arthrography Alternative for assessment of gleno-humeral instability (usually following dislocation) only when MRI is contraindicated or unavailable • Allows accurate evaluation of capsule / labral disorders • Disadvantage – invasive, radiation

13. SHOULDER PATHOLOGIES • Impingement syndrome • Rotator Cuff tear • Biceps tendon tear • Labrum and capsule • Osseous structures • Arthritis • Neural impingement • Tumors • Miscellaneous

14. SHOULDER PAIN • Symptoms: • Pain overhead • Pain and weakness • Pain with anything • Duration of symptoms

15. SHOULDER PAIN Rule out Extrinsic Sources Referred • Abdomen: subdiaphragmatic • Pulmonary disease: Pancoast tumor Radicular • Cervical Spine

16. SHOULDER EXAMINATION •General Shoulder Exam •Inspection – Skin ,Symmetry , Atrophy •Palpation – Bony prominance , Muscles and soft tissues •ROM •Neurovascular Exam •Impingement •Rotator Cuff •Labral Injury •Biceps Injuries •AC Joint

17. CERVICOGENIC PAIN • Spondylosis: “degeneration” • Ache into shoulders • Pain reproduced with ROM • Radiculopathy (weakness) • C 4-5: 5 root, pain to shoulder, (deltoid) • C 5-6: 6 root, lat forearm, thumb (biceps, ECRL) • C 6-7: 7 root, middle finger (triceps) • C 7-8: 8 root, small finger (finger flexion) • C8-T1: T1 root, medial arm (finger abduction)

18. IMPINGEMENT SYNDROME 4 types : (1) Primary impingement, (2) Secondary impingement, (3) subcoracoid impingement, and (4) Internal impingement. Impingement syndrome. Supraspinatus tendon is seen passing beneath coracoacromial arch

19. Impingement Tests A- Neer's impingement sign-positive B- Modified Neer's impingement sign Hawkins' impingement reinforcement test- abnormal

20. Jobe supraspinatus test Internal rotation resistance stress test Gerber subcoracoid impingement test

21. ROTATOR INTEGRITY TEST Jobes/empty can test - Supraspinatus isolation test - resistance painful and often weak Infraspinatus and teres minor resistance painful and possibly weak Teres minor isolation test

22. ROTATOR INTEGRITY TEST Subscapularis liftoff test Belly press test - napoleon sign Bear Hug test

23. Dropping sign Normal abnormal (infraspinatus tear and atrophy) Hornblower's sign abnormal (teres minor tear and atrophy) ROTATOR INTEGRITY TEST- LAG TEST

24. Subscapularis lag sign. A, Beginning. B. Normal. C. Abnormal Droparm sign usually indicates a large rotator cuff tear,

25. SLAP TEAR - Active Compression test ("O'Brien's Test") Crank Test

26. TEST FOR BICEPS INJURY Yergason's test Speed test Biceps instability test POPEYE SIGN

27. AC JOINT Acromioclavicular joint tenderness Cross-Body Adduction

28. ANTERIOR INSTABILITY • Anterior Load and Shift Apprehension and Relocation

29. POSTERIOR INSTABILITY • Posterior Load and Shift Jerk Test Posterior Apprehension Test

30. Drawer test A, Starting position. B, Anterior translation. C, Posterior translation.

31. MULTIDIRECTIONAL INSTABILITY (MDI) Sulcus Sign

32. IMPINGEMENT SYNDROME 4 Types : (1) Primary Impingement, (2) Secondary Impingement, (3) Subcoracoid Impingement, And (4) Internal Impingement.

33. ETIOLOGY - SECONDARY IMPINGEMENT • Os Acromiale • Type III Acromion • Acromioclavicular Degenerative Disease • Thickening Of The Coracoacromial Ligament • Coracoacromial Ligament Ossification • Low Lying Acromion • Post-traumatic Deformity • Shoulder Instability • Supraspinatus Over Development Extrinsic Intrinsic

34. Type 1- flat Type 2 – curved Type 3 – hooked Type 3 Hooked - associated with increased incidence of shoulder impingement Bigliani classification - shape of the acromion on outlet view radiographs On MRI

35. Coracoacromial ligament ossification MRI - impingement from supraspinatus with Acromioclavicular arthritis

36. OS ACROMIALE MRI – PD showing Os acromiale On axillary views

37. SUBCORACOID IMPINGEMENT • Pain - anterior shoulder - military parade rest position • Distance - 6.8 mm between the coracoid tip and the closest portion of the proximal humerus indicates impingement. Mri - increased signal within subscapularis muscle and tendon Narrowed coraco-humeral distance

38. Complete tear of the supraspinatus tendon with muscle retraction and fatty degeneration MRI Axial GRE -Narrowed coraco-humeral distance - subscapularis tendon tear and long head of biceps tendon dislocation

39. INTERNAL IMPINGEMENT Degeneration and tearing of infraspinatus and the posterior portion of the supraspinatus due to impingement by posterosuperior labrum and humeral head Postero-superior glenoid impingement Overhead throwing activities – athletes (throwers) Dynamic compression – occurs during abduction (> 120 degrees), retropulsion and extreme external rotation (ABER)

40. Fat-suppressed proton density image shows infraspinatus being impinged by posterosuperior glenoid labrum Infraspinatus tendon has increased signal near it insertion on greater tuberosity Cystic changes in posterosuperior humeral head near attachment sites of supraspinatus and infraspinatus tendons

41. CHRONIC ROTATOR CUFF TEAR WITH ARTHROPATHY may show a decreased acromiohumeral interval <7 mm on true AP shoulder radiograph in chronic tears

42. • high riding humerus • superior migration of the humeral head with decreased acromiohumeral distance • "acetabularisation" of the coracoacromial arch: pseudoarticulation of the humerus with the undersurface of the acromion causing concave acromial erosion and increased sclerosis - this can lead to impingement • decreased joint space in the superior aspect of the glenohumeral joint and associated osteoarthritic changes • "femoralisation" of the humerus: erosion and rounding of the greater tuberosity • osteopenia of the proximal humerus and acromion

43. ULTRASOUND Supraspinatus tendon full-thickness tear Supraspinatus tendon partial- thickness tear

44. Focal full-thickness supraspinatus tendon tears. Coronal oblique (a) and sagittal (b) fat-saturated T2-weighted MRI MRI

45. Partial-thickness tendon tears Coronal oblique fat-saturated

46. U-shaped tear of SST tendon Cresenteric shape of SST tendon tear

47. On The Basis Of Greatest Dimension As Either - Deorio And Cofield Classification • Small (1 Cm), • Medium (1–3 Cm), • Large (3–5 Cm), Or • Massive (5 Grading Rotator Cuff Tears On MRI Is As Follows: • grade 0: normal • grade I: increased T2 signal with normal morphology • grade II: increased T2 signal with abnormal morphology (thickening, or irregularity of the tendon) • grade III: defined tear (e.g. partial or full thickness, complete or incomplete)

48. • Both Articular-surface And Bursal-surface Partial-thickness Tears Are Graded According To Their Depth As Either • Grade 1 (3 Mm), • Grade 2 (3–6 Mm), Or • Grade 3 (6mm) • The Normal Rotator Cuff Is 10–12 Mm Thick; Thus, Grade 3 Tears Are Considered Significant Tears Involving More Than 50% Of The Cuff Thickness

49. • Tear Shape - The shape of a rotator cuff tear is important in theselection of a surgical technique. Tears can be classified arthroscopically into three basic shapes according to the tear geometry as viewed from the tendon surface: • crescentic, • U shaped, and • L shaped

50. ADHESIVE CAPSULITIS OF THE SHOULDER • frozen shoulder, is a condition characterised by thickening and contraction of the shoulder joint capsule and surrounding synovium • three distinct stages: • freezing: painful stage • frozen: transitional stage • thawing stage

51. RADIOGRAPHIC FEATURES FLUOROSCOPIC ARTHROGRAPHY • limited injectable fluid capacity of the glenohumeral joint • small dependent axillary fold • small subscapularis bursa • irregularity of the anterior capsular insertion at the anatomic neck of the humerus • lymphatic filling may be present

52. ADHESIVE CAPSULITIS OF THE SHOULDER Abnormal soft tissue thickening within the rotator interval , biceps , capsule and synovium with signal alteration

53. ULTRASOUND • limitation of movement of the supraspinatus is considered a sensitive feature • thickened coracohumeral ligament (CHL) can be suggestive • echogenic material around the long head of biceps at rotator interval • increased vascularity of long head of biceps at rotator interval

54. MRI/MR ARTHROGRAPHY • normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level; in adhesive capsulitis, the axillary recess may show thickening ≥1.3 cm • joint capsule thickening • abnormal soft tissue thickening within the rotator interval with signal alteration • abnormal soft tissue encasing the biceps anchor • variable enhancement of the capsule and synovium within the axillary recess and rotator interval • Other MR arthrography features include: • thickening of the coracohumeral ligament (CHL) • subcoracoid triangle sign

55. Abnormal soft tissue thickening within the rotator interval , biceps , capsule and synovium with signal alteration

56. CALCIFIC TENDINITIS deposition of calcium hydroxyapatite within tendons • supraspinatus: 80% • infraspinatus: 15% • subscapularis: 5% • periarticular soft tissues in addition to tendons • ligaments • capsule • bursae • lcium hydroxyapatite within tendons

57. PLAIN RADIOGRAPH • Calcific deposits are usually visualised as homogeneous hyperdensity with variable morphology, but typically globular/amorphous with poor margins. UGS

58. MRI • T1 • hypointense homogeneous signal • adjacent tendon may be thickened • some enhancement surrounding deposit may be seen • T2 • hypointense calcium deposits • hyperintense signal may be present peripherally due to oedema • hyperintense subacromial-subdeltoid bursal fluid • T2*: calcifications may bloom

59. Calcification at rotator cuff insertion.

60. CALCIFIC TENDINITIS

61. BICEPS TENDINITIS • Biceps tendon tender • Speed's test painful • Yergason's test painful (occasionally) • Biceps instability test abnormal (occasionally, if biceps tendon unstable) • Signs of concomitant rotator cuff tear (variable)

62. ULTRASOUND • Fluid in the tendon sheath (note: it communicates with the shoulder joint and is therefore non-specific) • thickening or thinning of the tendon • irregularity of the tendon borders • absence of the normal fibrillary appearance normal biceps tendon with the bridging transverse humeral ligament on the left side echogenic biceps tendon with its typical fibrillar pattern in its entire length on the right of the image. Anechoic halo of fluid around the biceps -right and fluid gravitating in the inferior triangular recess in on the left of this image with impending tendon subluxation

63. Thickening and diffuse T2 hyperintensity of the long head biceps tendon anchor.

64. BICEPS TENDONITIS USG MRI SHOWING BICEPS TEAR

65. DISLOCATION ANTERIOR DISLOCATION POSTERIOR DISLOCATION – LIGHT BULB SIGN

66. Bankart fracture (arrows) post-reduction view - very large fracture of the glenoid rim with displacement.

67. Bankart fracture (arrows)

68. BANKART AND VARIANTS

69. Bankart Lesion Osseous Bankart Lesion Reversed osseus Bankart in a patient with posterior dislocation.

70. Perthes Lesion - Labroligamentous Avulsion Anterior Labral Periosteal Sleeve Avulsion - medially displaced labrum Bankart lesion with extension into the cartilage, i.e a GLAD-lesion (red arrows)

71. Hill-Sachs at level of coracoid. Reverse Hill – Sachs lesion

72. • There are two types of labral tears: • SLAP tears start at the 12 o'clock position where the biceps anchor is located, which tears the labrum off the glenoid. SLAP tears typically extend from the 10 to the 2 o'clock position, but can extend more posteriorly or anteriorly and even extend into the biceps tendon. • Bankart lesions are typically located in the 3-6 o'clock position because that's where the humeral head dislocates.

73. Thank you !!!

Shoulder pathologies

Shoulder pathologies

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