clinical and radiological assessment

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 !!!