099.

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C H A P T E R

SHOULDER
99
Michael B. Zlatkin

INTRODUCTION 3204
TECHNICAL FACTORS 3204
Local Coils 3204
Pulse Sequences and
Parameters 3205
MRI Arthrography 3206
Imaging Protocols 3207
General Shoulder Anatomy 3207
MRI Anatomy 3214
ROTATOR CUFF DISEASE 3222
Pathophysiology 3222
Classification, Location, and Incidence
of Rotator Cuff Tears 3226
Magnetic Resonance Imaging 3227
SHOULDER INSTABILITY 3245
General Features 3245
Anterior Instability 3246
Posterior Instability 3250
POSTOPERATIVE SHOULDER 3259
Impingement and Rotator Cuff
Disease 3260
Deltoid Detachment 3262
Biceps Tendon Rupture 3262
Shoulder Instability 3262
OTHER DISORDERS 3266
Occult Fractures 3266
Muscle Injuries 3267
Inflammatory and Degenerative
Joint Processes 3268
Osteochondral Lesions 3269
Avascular Necrosis 3270
Quadrilateral Space Syndrome 3270
Parsonage-Turner Syndrome 3271

INTRODUCTION imaged, it is important that a radiofrequency coil

The shoulder is a joint capable of great freedom and
motion. It is therefore both inherently unstable and sub-
ject to injury. Shoulder pain is thus a common clinical
problem. It has a number of different etiologies, includ-
ing subacromial and other forms of impingement leading
to rotator cuff tendon failure, and various forms of
glenohumeral joint instability. These diseases may be
misdiagnosed clinically or dismissed with nonspecific
diagnoses, including bursitis or synovitis. In the absence
of a precise diagnosis, treatment may fail to relieve the
symptoms, resulting in chronic limitation of motion,
atrophy, and persistent pain.
MRI is accepted as the imaging modality of choice in
patients with shoulder pain. It is a useful and accurate
technique in noninvasively diagnosing many shoulder
disorders, particularly those due to rotator cuff disease
and shoulder instability. This chapter will review current
experience with this modality and discuss relevant tech-
nical, anatomic, and pathologic issues.
TECHNICAL FACTORS
Local Coils
Local radiofrequency coils are critical to MRI of joints,1
including the shoulder, as they provide greater diag-
nostic capability through an increase in signal-to-noise
ratio (SNR). Since noise is inherent in the tissue being
3204
adequately covers the area of interest, but covers as little
unwanted tissue as possible. In general, larger coils have
lower SNR; therefore, it is important to use the smallest
coil feasible to adequately encompass the area of
interest. Linear coils which consist of a single loop are
limited as the homogeneity of the image and SNR
degrade sharply away from the center of the loop,
producing suboptimal image quality for diagnosis of
deeper structures such as the labrum. Helmholtz coils,
consisting of two parallel loops with the anatomy of
interest sandwiched between them, provide better
homogeneity than a linear loop coil. The SNR perform-
ance is somewhat less than at the center of a loop.
Flexible coils are used commonly by some manufac-
turers. They consist of one or more linear loops that
wrap (once) around the area of interest. While flexible
coils offer good patient comfort and reasonable
diagnostic capability, their performance is easily sur-
passed by quadrature or array coils designed specifically
for imaging the shoulder. Quadrature (circularly
polarized, CP) coils provide significant improvements
in image quality over linear loop coils, with good SNR
and homogeneity available over the entire joint. Some
flexible coils may have a quadrature design. Flexible
quadrature coils have the “flexible” positioning options
of flex coils, but with superior SNR performance.
A multicoil (also known as phased) array consists of
two or more resonating loops. The output signal of each
loop is fed into an independent channel of the MRI
system. Since each channel is independent from the
others, the coil receivers do not share noise as long as
099.qxd 17/6/05 12:55 PM Page 3205
A B
F I G U R E 99-1
Technique. A, Four-channel array coil consisting of four linear coils arranged in a strip. The arrows represent the
B1 field of each coil in the array. B, Four-channel array shoulder coil positioned on a normal volunteer. Patients are
imaged in a supine position, with their arm by the side in the neutral rotation. (Courtesy of Tom Schubert, MRI
Devices Corporation, Waukesha, WI.)
they remain electrically isolated from each other.
Although MRI scanners can handle as many as 8 or 16
multicoil array channels, currently most shoulder array
coils are four-channel arrays (Fig. 99-1). Shoulder
multicoil arrays will permit imaging with high
resolution, small fields of view, and thin sections.
Pulse Sequences and Parameters
Conventional spin-echo sequences have for the most
part been replaced in MRI by fast spin-echo imaging
sequences. Short repetition time (TR)/time to echo (TE)
images are still, however, helpful to demonstrate
anatomic details and are most often used in MR
arthrography.
The tissue contrast is similar in fast spin-echo imaging
sequences to that seen with conventional spin echo;
however, fat is more intense on T2-weighted fast spin-
echo images, and therefore differentiating fat from fluid
signal can sometimes be difficult. Blurring of anatomic
structures is another problem, especially on short TE
sequences. Comparative studies have established the
efficacy of fast spin-echo techniques.2-6 Since marrow fat
is brighter, marrow edema can be obscured and fluid in
tears or in effusions may be more difficult to identify.
Thus most commonly, fat-suppression techniques are
added.
Gradient-echo sequences2,5,7-9 may be applied in
imaging the shoulder. These techniques can be used for
kinematic imaging10-15 and are also used to evaluate the
glenoid labrum. Problems with the gradient-echo
technique include the vacuum phenomenon,16 which
may simulate loose bodies or calcification, and increased
magnetic-susceptibility artifact.
Fat suppression is useful in shoulder MRI as it can
increase the conspicuity of an abnormality. This effect
is most prominent on T2-weighted sequences. Detec-
tion of abnormal enhancement after contrast injection
is improved on T1-weighted images by using fat sup-
C H A P T E R 99 ■ S HOULDER 3205
pression. TR and TE can also be reduced on T2-weighted
fast spin-echo sequences without loss of tissue contrast,
and imaging sequences with TEs in the 35 to 45 ms range
are often used with fat saturation in place of imag-
ing sequences with longer TEs and poorer SNR. Fat
suppression also reduces phase-encoding and chemical
shift artifacts. The two most common types of fat sup-
pression are short tau inversion recovery (STIR) imaging
and fat saturation. STIR images exhibit combined T1 and
T2 contrast, which enhance sensitivity but diminish
specificity. Fat saturation uses a radiofrequency pre-
saturation pulse applied at the resonant frequency of
lipid protons, followed by a gradient pulse designed to
spoil any residual signal intensity of fat. This technique is
better with high field-strength systems and a highly
uniform magnetic field.6,17 Methods such as STIR and fat-
saturation T2 can improve visualization of rotator cuff
tendon injuries (Fig. 99-2) and hyaline cartilage lesions,
and are also used to evaluate marrow abnormalities, and
inflammatory and post-traumatic processes. They may
also be useful to evaluate labral tears.
Performance of high-resolution imaging using large
matrices has recently become available, with systems
capable of performing 512 × 512 matrices, or using
parallel imaging, 3-T magnets, and appropriate coils even
higher matrices may be employed (Fig. 99-3). These
techniques may improve visualization of subtle abnor-
malities involving the labrum and rotator cuff. Smaller
fields of view18 are also helpful in the evaluation of the
shoulder. Large matrix and/or small field of view imaging
is made possible by higher field strength, improvements
in scanner hardware, better local coils, or such standard
factors as increased excitations and longer repetition
time. A narrow receiver bandwidth also improves SNR.
The slice thickness is also an important determinant
of spatial resolution. Slice thicknesses of 2 mm on two-
dimensional (2D) spin- and gradient-echo sequences
and thicknesses of 1 mm or less on 3D Fourier transform
(FT) images are available on most scanners for routine
usage. These are also very useful for evaluating such
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3206 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-2

Fat suppression. A, Conventional spin-echo T2-weighted image. B, T2-weighted fast spin-echo (FSE) image with fat
saturation. Fat saturation increases the conspicuity of the tendon disruption (arrows in A and B).

structures as the glenoid labrum and subtle injuries of

articular cartilage. Contiguous thin slices ensure that the
relevant anatomy is adequately covered and also reduce
partial volume averaging.

MRI Arthrography
In the absence of a native effusion MRI can be
performed after the injection of saline or a gadopentate
dimeglumine/saline mixture for MR arthrography.19-35 A
saline/gadopentate dimeglumine mixture (1.0 mL of
gadopentate dimeglumine/200 mL of saline) is injected.
This can be achieved by diluting 0.1 mL of gadolinium in
20 mL of saline. The amount depends on the capacity of
the joint, but is typically 12 to 15 mL, which is somewhat
greater than for conventional arthrography. The patient
is then taken to the MRI scanner and the appropriate
F I G U R E 99-3
image sequences are obtained. As mentioned earlier, fat-
saturation techniques are often utilized in conjunction to Image of the shoulder obtained with a four-channel phased-array coil at
increase the conspicuity of the contrast.32,34,36 Intra- 3 T. Note the severe tendinosis and small undersurface anterodistal partial
articular gadolinium distends the joint and potentially tear (arrow). (Courtesy of Larry Tannenbaum MD, Edison, NJ.)
can more directly identify abnormalities (Fig. 99-4). In
the shoulder, it is utilized to assess the rotator cuff
undersurface and to improve assessment of torn tendon
edges in complete cuff tears. It is very helpful in eval-
uating the postoperative shoulder and in assessing semi-invasive. Fluoroscopy is required for injection and
patients with glenohumeral instability and SLAP tears, therefore the total examination time is increased. Our
when findings are uncertain, or when there is no native patients are injected under C arm fluoroscopic guidance.
effusion.1 Positioning patients in abduction and external In addition, imaging may be logistically difficult to
rotation (ABER)37-39 may help visualize posterior under- perform if the scanner is remote from the fluoroscopic
surface lesions in posterosuperior subglenoid impinge- unit. Although no toxic effects are known, the intra-
ment and help to visualize labroligamentous abnor- articular use of gadolinium21 has not yet been approved
malities in complex instability cases, including Bankart by the Food and Drug Administration (FDA).
lesion variants. MR arthrography may help locate loose Indirect MR arthrography is achieved by injection
bodies but may not be as effective as CT air arthrography of paramagnetic MR contrast media intravenously
for this application. instead of as an intra-articular injection as in direct MR
Disadvantages of gadolinium injection are that it arthrography.40-43 In some cases, exercising the joint
requires an injection into the joint, making the study results in considerable signal intensity increase within
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C H A P T E R 99 ■ S HOULDER 3207

SCT
MGHL
AL

A B
F I G U R E 99-4

MR arthrography. T1-weighted images with fat saturation obtained after intra-articular gadolinium injection (1/200
dilution of gadolinium in saline). A, Coronal oblique image. Note the high signal obtained from gadolinium outlining
the cuff undersurface (arrow). B, Axial image shows the excellent delineation of the anterior labrum (AL), middle
glenohumeral ligament (MGHL), and subscapularis tendon (SCT) when the joint is distended with contrast. A small
posterior labral tear is seen (arrow).

the joint cavity where fat-saturated MR sequences yield
arthrographic images.44 The method is less invasive than
direct MR arthrography and initial results claim
comparable sensitivities and specificities for rotator cuff
and glenoid labrum pathology.45-47
Imaging Protocols
In shoulder imaging, patients are typically positioned
supine, with the arm at the side in a neutral rotation (see
Fig. 99-1B).With the arm in external rotation the capsule
is generally taut; with the arm in internal rotation it may
appear more redundant. External rotation is generally
avoided except under special circumstances, as this is
uncomfortable and may result in motion artifact. The
arm should not be placed on the chest or abdomen to
avoid transmitted respiratory motion.
In the routine shoulder protocol an axial dual-echo
proton-density and T2-weighted fast spin-echo pulse
sequence is obtained first with fat saturation. Some
examiners perform this sequence as an intermediate-
echo fast spin-echo sequence (TE 35-45 ms) with fat
saturation. Especially in patients with shoulder instability
this is followed by a sliced interleaved gradient-echo
(MPGR) T2* gradient-echo sequence, also in the axial
plane. The oblique coronal images are performed next
and are oriented from the axial images perpendicular to
the glenoid margin. Others orient these parallel to the
course of the supraspinatus tendon on axial images. This
sequence best evaluates the rotator cuff. A fast spin-echo
proton-density–weighted sequence is carried out,
without fat suppression, followed by a T2-weighted fast
spin-echo sequence with fat saturation. Sagittal oblique
images can be obtained with an intermediate-echo fast
spin-echo sequence with fat saturation.
MRI arthrography is performed in selected cases as
discussed earlier (see Fig. 99-4). Twelve to 15 mL of con-
trast is injected. T1-weighted images with fat saturation
in the axial, coronal oblique, and sagittal oblique planes
are obtained. This is then followed by a T2-weighted fast
spin-echo sequence, typically in the axial and coronal
oblique planes.
The field of view is 12 to 14 cm and the slice thick-
ness is 3 to 4 mm. The matrix size is 256 × 192 or
256 × 256 for the T1 and gradient-echo sequences. For
fast spin-echo imaging, a 384 × 256 matrix is employed
with an echo train of three to four for the proton-
density–weighted images and seven to eight for the
T2-weighted images.
General Shoulder Anatomy
The shoulder enjoys a greater range of motion than any
other joint in the body. In fact it is not a single joint, but
the synergistic action of four separate articulations:
glenohumeral, acromioclavicular, sternoclavicular, and
scapulothoracic joints.
Glenohumeral Joint
The glenohumeral joint is a multiaxial ball and socket
joint lying between the roughly hemispheric humeral
head and the shallow glenoid fossa of the scapula.48 The
glenoid fossa is essentially a pear-shaped cavity with
dimensions approximately a quarter the size of the
humeral head.49 The glenoid is covered by articular
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3208 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-5
Rotator cuff muscles and tendons. Note the supraspinatus tendon inserts
more superiorly and anteriorly on the greater tuberosity, and the
infraspinatus and teres minor more posteriorly and inferiorly. The
subscapularis is anterior and inserts broadly in a fanlike fashion on the lesser
tuberosity. ISM, infraspinatus muscle; IST, infraspinatus tendon; SSM,
supraspinatus muscle; SST, supraspinatus tendon; SCM, subscapularis
muscle; SCT, subscapularis tendon; TM, teres minor muscle; TMT, teres
minor tendon. (Reproduced with permission from Zlatkin MB: MRI of the
Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)
cartilage that is thinner centrally. The humeral head is
also covered with articular cartilage which thins
slightly at the periphery to accentuate glenohumeral
joint congruity.50 This anatomy permits a wider range of
motion than is possible at any other joint. The shoulder
is capable of flexion-extension, abduction-adduction,
circumduction, and medial and lateral rotation.48 This
anatomy provides mobility, but renders the joint unstable
and prone to subluxation and dislocation. This is due to
the small size of the glenoid fossa compared to the
humeral head and the relative laxity of the joint capsule.
These movements and the associated inherent insta-
bility of the glenohumeral joint may also be important in
the development of internal impingement in the
overhead throwing athlete.51
The proximal end of the humerus consists of the head
and greater and lesser tuberosities. The humeral head is
normally retroverted approximately 30 degrees with the
arm in the anatomic position. The articular surface is
directed superiorly, medially, and posteriorly with an axis
angled 130 to 150 degrees relative to the humeral shaft.50
The anatomic neck of the humerus lies at the base of the
articular surface at the proximal end of the bone. The
neck is the site of attachment of the inferior aspect of
the joint capsule. The greater tuberosity is located on the
lateral aspect of the proximal humerus and is the site of
insertion of the supraspinatus, infraspinatus, and teres
minor tendons (Fig. 99-5). The supraspinatus tendon
F I G U R E 99-6
Coracoacromial arch and surrounding structures. Note the relationship of
the supraspinatus tendon to the anterior acromion, acromioclavicular joint,
and coracoacromial ligament. The long head of the biceps tendon is also an
important relation of this arch. ACJ, acromioclavicular ligament; ACR,
acromion; BT, biceps tendon; CAL, coracoacromial ligament; SCT
subscapularis tendon; SST, supraspinatus tendon; TL, transverse humeral
ligament. Arrow, biceps tendon sheath. (Reproduced with permission from
Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams
and Wilkins, 2003.)
inserts on the highest point of the greater tuberosity
(Fig. 99-5). The infraspinatus and teres minor tendons
localize, respectively, to the middle and lower thirds of
the greater tuberosity and lie somewhat more posteriorly
than the supraspinatus tendon insertion. The lesser
tuberosity is situated on the anterior portion of the
proximal humerus, medial to the greater tuberosity.
The subscapularis tendon inserts here in a broad band
(Fig. 99-5).
The intertubercular (bicipital) groove is located
between the greater and lesser tuberosities. The trans-
verse humeral ligament stretches between the two
tuberosities, forming the roof of the intertubercular
groove. The tendon of the long head of the biceps brachii
muscle passes through here, surrounded by a synovial
sheath (Fig. 99-6). The width of the groove can vary and
if shallow this may predispose it to impingement. Below
the greater and lessor tuberosities, the humerus tapers to
the surgical neck. The intertubercular groove at this
level normally then becomes shallower, and its medial
lip provides the insertion site for the latissimus dorsi
and teres major tendons; its lateral lip provides the inser-
tion site for the pectoralis major.50 The deltoid inserts
along the deltoid tuberosity, a smooth broad bony
prominence on the midportion of the diaphysis. The
coracobrachialis also inserts at this level along the medial
border of the humerus. The long head of the triceps
muscle attaches to the infraglenoid tubercle, which is a
099.qxd 17/6/05 12:55 PM Page 3209
F I G U R E 99-7
Cross-sectional diagram illustrating important structures and relations of
the shoulder. ACR, acromion; AR, axillary recess; CL, clavicle; D, deltoid
muscle; SDB, subacromial-subdeltoid bursa; SSM, supraspinatus muscle;
SST, supraspinatus tendon. (Reproduced with permission from Zlatkin MB:
MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins,
2003.)
triangular surface where the inferior glenoid rim joins
the lateral scapular border.50
Hyaline articular cartilage lines the surfaces of the
humeral head. The cartilage on the humeral head is
thickest at its center. The blood supply to the humeral
head is via the anterior humeral circumflex artery. There
is a normal “sulcus” located posteriorly on the humeral
head.52 This represents an area of “bare bone” between
the insertion of the posterior capsule and overlying
synovial membrane and the edge of the articular surface
of the humeral head. The appearance of this sulcus on
cross-sectional images has sometimes been confused
with a Hill-Sachs lesion.
The glenoid fossa is situated on the superolateral
aspect of the scapula (Figs. 99-7 and 99-8). The superior
portion of the fossa is narrow and the inferior portion is
broad. In man there is greater anterior tilt to the glenoid
fossa and therefore greater anterior instability.53,54 The
glenoid fossa is lined by articular cartilage, thinner in the
center. The glenoid labrum rims the glenoid cavity, and
provides inherent stability to the glenohumeral joint,
restricting anterior and posterior excursion of the
humerus (Figs. 99-7 and 99-8).49 The labrum consists of
hyaline cartilage, fibrocartilage, and fibrous tissue.
Fibrocartilage is present in the labrum only in a small
transition zone at the attachment to the osseous glenoid
rim. The blood supply of the labrum is mainly to the
outermost portion of the labrum. The inner portion is
without vessels.
The glenoid labrum is variable in size and thickness.
In young patients the labrum is closely attached at its
base to the glenoid, blending with the fibrils of hyaline
articular cartilage. In later years especially the superior
C H A P T E R 99 ■ S HOULDER 3209
F I G U R E 99-8
Capsular mechanism and surrounding structures. The capsule and
glenohumeral ligaments are seen. The superior labrum, superior
glenohumeral ligament, and biceps tendon converge superiorly. The
convergence of the superior labrum and biceps tendon superiorly is known
as the biceps labral anchor. There is an opening into the subscapularis bursa
between the middle and superior glenohumeral ligaments. The inferior
glenohumeral ligament merges with the labrum inferiorly. It is divided into
an anterior band, axillary pouch, and posterior band. 1, subscapularis
muscle; 2, anterior capsule; 3, superior glenohumeral ligament; 4, middle
glenohumeral ligament; 5, inferior glenohumeral ligament; AB, anterior
band; AP, axillary pouch; PB, posterior band; 6, biceps tendon, long head;
7, posterior capsule; 8, posterior rotator cuff; L, glenoid labrum;
G, glenoid. (Reproduced with permission from Zlatkin MB, Bjorkengren AG,
Gylys-Morin V, et al: Cross-sectional imaging of the capsular mechanism of the
glenohumeral joint. Am J Roentgenol 150:151-158, 1988.)
portion of the labrum may rest free on the edge of the
glenoid. This may arise as a result of pull by the superior
glenohumeral ligament and biceps tendon and may be
distinguished from a labral tear by its smooth borders. In
young athletes superior quadrant labral tears may result
from traction by these same two structures in overhead
throwing.55
The fibrous glenoid labrum deepens and enlarges the
shallow glenoid fossa. The glenoid is also deepened by
the thin cartilaginous lining in the center of this
structure. The labrum is also important as a site for
ligamentous attachment (see Fig. 99-7).56 It is believed
that the strong intertwining between the collagen fibers
of the glenohumeral ligaments and the labrum is more
resistant to injury than the glenolabral junction/union.
There appears to be a strong pathophysiologic relation-
ship between the locations of labral lesions and the
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3210 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
attachment sites of the glenohumeral ligaments and
proximal biceps tendon (see Fig. 99-8).57,58 The inferior
portion of the labral-ligamentous complex is more
important than the superior portion in stabilizing the
glenohumeral joint. It is this portion of the labrum that is
more commonly injured in patients with anterior
glenohumeral instability. Nonethelesss, the superior
labrum does play some role in the stability of the
glenohumeral joint where it functions in conjunction
with the biceps tendon, through the biceps labral com-
plex (see Fig. 99-8). The superior and anterior superior
portions of the labrum are the more variable in their
attachment to the glenoid, while the more inferior
portion of the labrum is typically fixed.
A loose, redundant fibrous capsule envelops the joint.
It is lined by a synovial membrane, and has a surface area
approximately twice that of the humeral head (see
Figs. 99-7 and 99-8).50 It encompasses all the intra-
capsular soft-tissue structures, including the biceps
tendon, glenohumeral ligaments, labrum, and synovial
recesses. In the bursal recesses this membrane may be
redundant. Superiorly, the capsule encroaches on the
root of the coracoid process and inserts in the supra-
glenoid region. Laterally the capsule inserts into the
anatomic neck of the humerus and inferiorly into
the periosteum of the humeral shaft.With the arm at the
side the lower part of the capsule is lax, forming
the axillary recess (see Figs. 99-7 and 99-8). Posteriorly
and inferiorly, the capsule is continuous with the cap-
sular border of the labrum and the adjacent bone.
Medially, the anterior capsular insertion may be variable59
based on its relationship to the glenoid labrum. It may
insert directly into the labrum.60 In a smaller percentage
of cases it may insert progressively more medially along
the scapular neck, which has been considered to be less
stable. Investigation with MRI and MR arthography has
called into question the correlation between the type of
capsular insertion and glenohumeral instability.61
The fibrous capsule is strengthened in several areas.
The coracohumeral ligament is a strong fibrous band
extending from the coracoid process over the humerus
to attach to the greater tuberosity. It has a more impor-
tant function in shoulder stability than previously
thought.62-65 It also supports the long head of the biceps
tendon in the intertubercular groove, and it is disruption
of this structure rather than the subscapularis tendon, or
its extension into the transverse humeral ligament, that
appears to be the main cause of intra-articular subluxa-
tion of the biceps tendon. Anteriorly, the capsule may
thicken to form the superior (SGHL), middle (MGHL),
and inferior glenohumeral ligaments (IGHL) (Figs. 99-8
and 99-9).66-68 These ligaments reinforce the anterior
portion of the capsule and act as a check to external
rotation of the humeral head.66,69 They extend from
adjacent to the lesser tuberosity to the anterior border of
the glenoid fossa.
The superior glenohumeral ligament, together with
the coracohumeral ligament, stabilizes the shoulder joint
when the arm is in the adducted dependent position.
The ligament consists of two proximal attachments; one
to the superoanterior aspect of the labrum conjoined
with the biceps tendon, and the other to the base of the
coracoid process (Figs. 99-8, 99-9, and 99-10). This
ligament projects in a lateral fashion to insert along the
anterior aspect of the anatomic neck of the humerus,
superior and medial to the lesser tuberosity.49,52
The middle and inferior glenohumeral ligaments
blend with the labrum at a level lower than that of the
superior ligament (see Figs. 99-8, 99-9, and 99-10). These
ligaments and the recesses between them are quite
variable.66,69 The greatest variation is in relation to the
middle glenohumeral ligament. This ligament provides
stabilization to the glenohumeral joint when the
shoulder is abducted 45 degrees. It originates from just
beneath the superior glenohumeral ligament along
the anterior border of the glenoid to the junctions
of the middle and inferior third of the glenoid rim. It
blends with the anteroinferior aspect of the capsule,
and inserts along the anterior aspect of the surgical
neck of the humerus, anterior and inferior to the lesser
tuberosity.49,52
The inferior glenohumeral ligament has a complex
configuration (see Figs. 99-8, 99-9, and 99-10).70,71 It may
be identified as a distinct structure or as just a diffuse
thickening of the capsule. It is the thickest portion of the
capsule. It consists of three portions: anterior band,
posterior band, and axillary pouch/recess of the capsule.
It stabilizes the glenohumeral joint when the arm is
abducted to approximately 90 degrees (see Figs. 99-8,
99-9, and 99-10).22,72 The ligament has a triangular con-
figuration with its origin from the anteroinferior and
posterior margin of the glenoid rim below its epiphyseal
line and its origin is inseparable from the base of the
labrum. The inferior glenohumeral ligament inserts along
the inferior aspect of the surgical neck of the humerus.
The capsule is reinforced by the tendons of the
rotator cuff muscles: the supraspinatus, infraspinatus,
teres minor, and subscapularis muscles. These tendons
all blend with the fibrous capsule to form the musculo-
tendinous cuff (see Fig. 99-5). The primary function of
the supraspinatus muscle and tendon complex is to
abduct the humerus, but it also has a role in humeral
rotation, and also functions as a counterbalance to the
deltoid by depressing the humeral head.50 The inner-
vation of the supraspinatus muscle is by the supra-
scapular nerve (C5 and C6 roots), which passes through
the suprascapular notch. The suprapinatus tendon may
consist of two distinct portions. The ventral portion
originates from the anterior supraspinatus fossa inserting
anteriorly onto the greater tuberosity. This ventral
portion of the supraspinatus tendon may additionally
have a site of insertion onto the lesser tuberosity and
there may function as an internal rotator of the arm. The
second portion of the supraspinatus is located more
posteriorly, in a “straplike” configuration. It has several
small tendon slips which coalesce into a broad fibrous
attachment inserting more posteriorly onto the greater
tuberosity. This portion acts primarily as a shoulder
abductor.73 In addition, medially originating fibers from
both muscle portions merge in a bipennate fashion
to form a strong tendon eccentrically located within
the muscle.
The main function of the infraspinatus muscle-tendon
unit is external rotation. It also functions to depress the
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C H A P T E R 99 ■ S HOULDER 3211

SGHL
SGHL

BT BT AL

BLC AL

PL PL
B

SCB
A AC

SCB
SCT

MGHL AL

SCT
D

MGHL
IGHL
AL

PL
C L

IGHL

F
F I G U R E 99-9

Cross-sectional anatomy of the glenohumeral ligaments and surrounding structures (axial plane). MR images (TR/TE
800/20 ms) with fat saturation obtained after intra-articular gadolinium injection, and corresponding cadaver sections.
A and B, Superior attachments of the superior glenohumeral ligament are seen with the biceps tendon into the
superior glenoid, with the superior labrum, and more anteriorly along the coracoid. The confluence of the biceps
tendon long head and superior labrum forming the biceps-labral anchor is also seen. AL, anterior superior labrum;
BLC, biceps-labral complex; BT, biceps tendon long head; PL, posterior superior labrum; SGHL, superior gleno-
humeral ligament. C and D, Midglenoid level shows the relationship of the anterior labrum (AL) to the middle
glenohumeral ligament (MGHL), anterior capsule (AC), and subscapularis tendon (SCT). The subscapularis bursa is
continuous with the joint and extends anterior to the subscapularis tendon (SCB). E and F, Anterior inferior glenoid
level. Here the anterior band of the inferior glenohumeral ligament (IGHL) and subjacent capsule is thick and forms
a complex with the labrum (L), which is usually also round and thick at this level.
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3212 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

BT
BT
MGHL SGL

SCT SCT AP
AB
A B
F I G U R E 99-10

Glenohumeral ligaments. A and B, Sagittal oblique MR (TR/TE 600/20 ms) images with fat saturation obtained
after intra-articular gadolinium injection. The anterior band (AB) (A) and axillary pouch portions (AP) (B) of the
inferior glenohumeral ligament can be well seen in this plane when contrast is present. The oblique course of
the middle glenohumeral ligament is noted (MGL) (A). A small portion of the superior glenohumeral ligament (SGL)
is visible (B). BT, biceps tendon; SCT, subscapularis tendon.

humeral head, and as a static stabilizer of the gleno-
humeral joint, resists posterior subluxation.50 The
infraspinatus muscle is innervated by the distal fibers of
the suprascapular nerve. The infraspinatus tendon is
posterior to the supraspinatus tendon and inserts on the
middle facet of the greater tuberosity, inferior and
posterior to the supraspinatus tendon.
The teres minor is posteroinferior to the infraspinatus
(see Fig. 99-5). It is a powerful external rotator of the
humerus. It also helps resist subluxation of the humeral
head.50 The teres minor muscle is innervated by
branches of the axillary nerve. It also forms part of the
border of the quadrilateral space as well as the trian-
gular space.
The subscapularis is the largest and most powerful
muscle of the rotator cuff with a broad-based belly that
originates from the anterior scapula (see Fig. 99-5). It has
four to six strong tendon slips that arise medially deep
within the muscle. These slips converge to form a main
tendon that inserts along the superior aspect of the
lesser tuberosity.74 Additional tendon fibers from the
subscapularis merge with the transverse humeral
ligament and extend across the floor of the bicipital
groove, fusing with those of the supraspinatus tendon
into a sheath that encompasses the biceps tendon.75 The
subscapularis muscle is supplied by the upper and lower
subscapular nerve.50 In addition to the subscapularis’
primary role in active internal rotation, it also functions
in adduction, depression, flexion, and extension. The
subscapularis tendon also reinforces the anterior joint
capsule. It is separated from the rest of the rotator cuff
tendons by the rotator cuff interval.
The rotator cuff tendons fuse along their distal
attachments to the greater and lesser tuberosities to
provide a continuous water-tight unit.76 Prior to their
fusion, the anatomic space between the supraspinatus
and subscapularis along the anterosuperior aspect of
the shoulder is the rotator interval (Fig. 99-11). It is a
complex region and can be conceptualized in layers.68,77,78
The outermost layer consists of fibrofatty tissue and
beneath this is the coracohumeral ligament, the rotator
interval capsule, and then the superior glenohumeral
ligament. The coracohumeral ligament courses from
the coracoid process into the interval, fusing with the
interval capsule. This capsule/ligament complex extends
superiorly merging and fusing with the anterior
margin and superficial/deep fascial fibers of the supra-
spinatus anteriorly. The interval capsule and ligament
also extend inferiorly to the superior margin of the sub-
scapularis, and project laterally to insert on the greater
and lesser tuberosities. The superior glenohumeral
ligament also is a contributor to this complex of struc-
tures, originating from the supraglenoid tubercle con-
tiguous to the attachment of the long head of the biceps
tendon (LHB), and then coursing laterally to insert at
the lesser tuberosity, where it fuses with the coraco-
humeral ligament.76 This fused rotator interval capsule
and coracohumeral ligament are important stabilizers
and anterosuperior supporting structures for shoulder
function, and can be conceptualized as a roof over the
intra-articular course of the biceps tendon, which is
the deepest structure in the interval. When the interval
capsule and coracohumeral ligament are disrupted,
the shoulder may be susceptible to posterior inferior
subluxation and instability.76
The biceps brachii functions primarily as a supinator
of the forearm and a flexor of the elbow joint. There are
two tendinous origins of the biceps muscle. Its role is
in stabilizing the humeral head in the glenoid during
abduction of the shoulder.79 The intra-articular portion of
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C H A P T E R 99 ■ S HOULDER 3213

the LHB arises from the supraglenoid tubercle (see Figs.

BT 99-8, 99-9, 99-10, and 99-12) and the posterosuperior
SS
glenoid labrum. It runs across the superomedial aspect
CHL of the humeral head and enters the intertubercular
sulcus which is formed by the greater tuberosity, lesser
IS tuberosity, and soft tissues, including the insertion of the
subscapularis tendon and coracohumeral ligament.79 It
penetrates the rotator cuff between the supraspinatus
SGH
and subscapularis at the rotator interval. The biceps
tendon is surrounded by a synovial sheath, which is
continuous with the synovial sheath of the shoulder
joint (see Fig. 99-6). The anterior relationships of the
proximal long head of the biceps include the coraco-
TM humeral ligament, the superior glenohumeral ligament,
MGH the anterior supraspinatus tendon, and the subscapu-
laris tendon. These are the stabilizers of this portion
of the tendon. The tendon is secured within the groove
by the transverse humeral ligament, which passes
between the tuberosities, over the synovial sheath of
the tendon. The transverse humeral ligament is formed
SC by a few fibers of the capsule, or as a continuation of the
subscapularis tendon. The biceps tendon mainly func-
tions through its distal insertion at the elbow, but also
has some function at the shoulder where it acts as a
stabilizer, as well as a humeral head depressor. It is closely
associated functionally with the rotator cuff. The short
IGH T head of the biceps arises from the tip of the coracoid
F I G U R E 99-11 process. The conjoined tendon of the coracobrachialis
muscle and the short head of the biceps brachii muscle
Rotator interval structures. Sagittal diagram through the left shoulder
join on the tip of the coracoid process.
showing structures of the anterior interval. The first layer of the interval
includes the subscapularis (SC) and supraspinatus (SS) tendons, and the
There are a number of bursae about the glenohumeral
coracohumeral ligament (CHL). Deep to this is the articular capsule (arrow) joint. The subdeltoid bursa is the largest bursa in the
followed by the superior glenohumeral ligament (SGH) and the biceps human body (see Fig. 99-7). It is comprised primarily of
tendon (BT) and its sheath. Also shown is the infraspinatus (IS), teres minor a subacromial and subdeltoid portion which commu-
(TM), middle glenohumeral ligament (MGH), inferior glenohumeral nicate. The size and configuration of the subdeltoid bursa
ligament (IGH), and triceps long head (T). varies. The bursa is firmly adherent to the periosteum

A B
F I G U R E 99-12

Biceps tendon. A, Coronal oblique MR images (TR/TE 600/20 ms) with fat saturation obtained after intra-articular
gadolinium injection. B, Corresponding anatomic section. The long head of the biceps tendon is seen extending from
the supraglenoid region into the intertubercular groove (arrows in A and B).
099.qxd 17/6/05 12:55 PM Page 3214
3214 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
of the undersurface of the acromion, coracoacromial
ligament, and superior surface of the rotator cuff. Its
lateral extent projects deep to the deltoid muscle
approximately 3 cm along the outer margin of the
greater tuberosity. Medially, the bursa exhibits consider-
able variability extending as far as 2 cm medial to the
acromioclavicular joint. Anteriorly, the bursa covers the
superior aspect of the bicipital groove; posteriorly, the
bursa extends between the deltoid muscle and rotator
cuff musculature. There is continuity between the
subdeltoid and subacromial components. The bursa is a
synovial-lined potential space within a fine layer of
mature areolar/adipose tissue that lubricates motion
between the rotator cuff and the acromion and
acromioclavicular joint; hence it is often inflamed in
patients with impingement and rotator cuff disease. It
only communicates with the joint if a full-thickness tear
of the rotator cuff opens through the joint capsule into
the floor of the bursa.
The subcoracoid bursa resides between the
subscapularis tendon and the combined tendon of the
coracobrachialis and the short head of the biceps
tendon. It is identified in nearly 97% of gross specimens,
and communicates with the subdeltoid bursa in 11% of
anatomic specimens.80 The subcoracoid bursa should
not communicate with the glenohumeral joint. Sub-
coracoid bursitis may be a rare cause of nonspecific
anterior shoulder discomfort.
The subscapularis bursa is found in up to 90% of
the population (see Figs. 99-8 and 99-9). It is really an
outpouching of the glenohumeral joint protruding
between the superior and middle glenohumeral liga-
ments and residing between the posterior aspect of the
subscapularis muscle/tendon and the anterior surface of
the scapula. The opening into the bursa between these
two ligaments is known as the foramen of Weitbrecht.
The subscapularis bursa communicates with the joint
cavity and protects the subscapularis tendon as it passes
under the coracoid, or over the neck of the scapula. The
subscapularis recess may extend anterior to the
subscapularis tendon and acts as a gliding mechanism for
it (see Fig. 99-9).
Acromioclavicular Joint
The acromioclavicular joint is a small, immobile synovial
articulation between the medial aspect of the acromion
and the lateral portion of the clavicle (see Figs. 99-6 and
99-7). The articular surfaces of the acromion and clavicle
are covered with fibrocartilage. In the central portion of
the joint there is an articular disk which is fibrocar-
tilaginous. A synovium-lined articular capsule surrounds
the joint. It is reinforced by the superior and inferior
acromioclavicular ligaments. The inferior portion of the
joint is also reinforced by fibers of the coracoacromial
ligament.50 The coracoclavicular ligament is more
important to stability and forms a fanshaped ligament
complex that connects the base of the coracoid process
to the overlying clavicle. This ligament has two com-
ponents, the posteromedial conoid and anterolateral
trapezoid ligaments.
The coracoacromial arch (see Fig. 99-6) is a strong
bony and ligamentous arch that protects the humeral
head and rotator cuff tendons from direct trauma.59 It
consists of the acromion, acromioclavicular joint,
coracoid process, and coracoacromial ligament. Portions
of the rotator cuff tendons, including the supraspinatus
tendon and the superior 20% of the infraspinatus and
subscapularis tendons, pass under this arch as they
extend to their insertion on the humerus.50 The coraco-
acromial ligament is unyielding. It limits the space
available to the rotator cuff, subdeltoid bursa, and biceps
in overhead motion. The ligament can vary in appear-
ance.81 In approximately two-thirds of subjects the
ligament morphology follows the classical description; a
strong, fibrous, triangular-shaped structure comprising
two conjoined or closely adjacent bands. In the other
third of cases, the base of the ligamentous triangle is
broadened and extends posteriorly all the way to the
base of the coracoid. This broad acromial insertion site
is thought to be worsened with certain acromial shapes,
thickening of the coracoacromial ligament, and bony
osteophytes on the anterior acromion or acromioclav-
icular joint. This may then contribute to the process of
chronic impingement.
Acromial morphology has been categorized utilizing
plain radiographic analysis: type I flat, type II curved, and
type III hooked (Fig. 99-13).82-84 This configuration can
be assessed with sagittal MR images, though this has met
with variability and poor reliability among investi-
gators.85,86 The J- or hook-shaped type III morphology
has the highest association with impingement syndrome
and rotator cuff abnormalities.87
The coracohumeral ligament originates from the
lateral margin of the base of the coracoid process, blends
with the supraspinatus tendon, and attaches to both the
greater and lesser tuberosities, creating a tunnel for the
biceps tendon. This ligament stabilizes the long head of
the biceps tendon and also projects within the rotator
interval (see Fig. 99-11).88,89
The suprascapular notch lies just lateral to the base of
the coracoid process. The superior transverse scapular
ligament converts the notch to a foramen through which
the suprascapular nerve passes. The suprascapular vessels
project superior to this ligament.50
MRI Anatomy (Figs. 99-14 to 99-16)
The normal MR appearance of the shoulder in the axial,
coronal oblique and sagittal oblique planes is illustrated
in Figures 99-14 to 99-16. In the normal state, subcuta-
neous fat, intermuscular fat planes, and bone marrow
normally have the highest signal on short TR/TE or
long TR short TE images, due to their relatively short
T1. On long TR/TE images, they are of intermediate
signal intensity. Muscles and hyaline cartilage have an
intermediate-to-high signal intensity on all spin-echo
pulse sequences, and on gradient-echo sequences articu-
lar cartilage tends to have high signal intensity. Due to
a relative lack of mobile protons, a long T1, and a short
T2, certain structures should have essentially a very
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C H A P T E R 99 ■ S HOULDER 3215

F I G U R E 99-13

Acromion shape. Three types of anterior acromion:

type 1, flat; type 2, curved; type 3, hook shaped.
(Reproduced with permission from Zlatkin MB: MRI of
the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams
and Wilkins, 2003.)

ANTERIOR
supraspinatus
ANTERIOR infraspinatus tendon biceps tendon
tendon long & short heads
infraspinatus
tendon
deltoid
coracoid
LATERAL process
LATERAL SGHL
humeral
head

supraspinatus
m.

A B
scapular spine labrum,
superior supraglenoid
tubercle

ANTERIOR
supraspinatus biceps tendon, coracoid
tendon long head process

pectoralis minor
infraspinatus
tendon & muscle
tendon
F I G U R E 99-14

A-C, Axial MRI and MR arthrographic anatomy. Superior to inferior.

SGHL
labrum, Short TR/TE images (800/20 ms). IGHL, inferior glenohumeral ligament;
LATERAL anterosuperior MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral liga-
glenoid ment; a., artery; m., muscle; n., nerve; t., tendon. (Prepared by Steven
Needell, MD; reproduced with permission from Zlatkin MB: MRI of the
deltoid Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)
articular Continued
C cartilage

labrum,
posterosuperior
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3216 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

ANTERIOR
ANTERIOR
long head of
transverse ligament biceps tendon
biceps tendon, long heads in intertubercular subscapularis
subscapularis tendon groove tendon
LATERAL pectoralis
major corachorachialis
m.
subscapularis
greater pectoralis minor
bursa LATERAL
tuberosity m.
MGHL
lesser infraspinatus
labrum, tendon
tuberosity MGHL
anterior & muscle
articular
cartilage
labrum,
glenoid anterior

D E subscapularis
m.
labrum, infraspinatus labrum,
posterior m. posterior
suprascapular a. & n.
in spinoglenoid notch

ANTERIOR
transverse ligament ANTERIOR
subscapularis
biceps tendon tendon biceps tendon, coracobrachialis
IGHL, anterior band long head m.
pectoralis
major m.

LATERAL

LATERAL
subscapularis
teres minor tendon &
tendon muscle
deltoid
& muscle labrum,
anteroinferior

teres minor
F G m.
labrum,
articular labrum, inferior
labrum,
anteroinferior
posteroinferior cartilage

F I G U R E 99-14, cont’d

D-G, Axial MRI and MR arthrographic anatomy. Superior to inferior. Short TR/TE images (800/20 ms). IGHL, inferior glenohumeral ligament; MGHL, middle
glenohumeral ligament; SGHL, superior glenohumeral ligament; a., artery; m., muscle; n., nerve; t., tendon. (Prepared by Steven Needell, MD; reproduced
with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)
099.qxd 17/6/05 12:55 PM Page 3217

C H A P T E R 99 ■ S HOULDER 3217

SUPERIOR
biceps tendon, coracoid biceps-labral
short head process complex clavicle

clavicle
supraspinatus
supraspinatus m.
supraglenoid
tendon tubercle
deltoid
m. subscapularis greater
tuberosity subscapularis
tendon &
of humeral tendon &
muscle MEDIAL
head muscle
biceps
axillary vessels tendon,
long head

brachial plexus

A B
coracobrachialis coracobrachialis
m. m.

SUPERIOR suprascapular
labrum, deltoid artery & nerve in
acromion clavicle superior muscle acromion spinoglenoid notch

coracoacromial
ligament supraspinatus
supraspinatus supraspinatus
supraspinatus m.
tendon m.
tendon suprascapular
artery & nerve
humeral
head glenoid
MEDIAL
IGHL
subscapularis IGHL
m.
brachial subscapular
artery m.

C D
biceps tendon, coracobrachialis biceps tendon,
long head m. long head

F I G U R E 99-15

A-D, Coronal oblique MRI and MR arthrographic anatomy. Anterior to posterior. Short TR/TE images (800/20 ms). IGHL, inferior glenohumeral ligament
MGHL; middle glenohumeral ligament; SGHL, superior glenohumeral ligament; subscap, subscapularis; pect., pectoralis; m., muscle; t., tendon. (Prepared
by Steven Needell, MD; reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)
Continued
099.qxd 17/6/05 12:55 PM Page 3218
3218 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
SUPERIOR
deltoid infraspinatus
muscle acromion muscle
trapezius
muscle
infraspinatus
tendon
labrum,
posterior
MEDIAL
subscapularis
E muscle
teres minor
muscle
F I G U R E 99-15, cont’d
E and F, Coronal oblique MRI and MR arthrographic anatomy. Anterior to posterior. Short TR/TE images (800/20 ms). IGHL, inferior glenohumeral ligament
MGHL; middle glenohumeral ligament; SGHL, superior glenohumeral ligament; subscap, subscapularis; pect., pectoralis; m., muscle; t., tendon. (Prepared
by Steven Needell, MD; reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)
low or no MR signal. These structures include cortical
bone, glenoid labrum, fibrous capsule, glenohumeral and
other ligaments and tendons, such as the tendinous
insertions of the rotator cuff musculature, and long head
of biceps tendon, as it courses in the bicipital groove.90,91
Numerous studies have shown that signal may be
present in the ligaments, tendons, and fibrocartilage of
asymptomatic people due to age-related degeneration,
subclinical pathology, partial volume averaging of normal
tissues, or artifacts including magic angle effects.92-99
Axial images (Fig. 99-14) demonstrate the relationship
between the humeral head and glenoid fossa. Articular
cartilage and the glenoid labrum are well depicted. The
superior and middle portions of the anterior glenoid
labrum are usually triangular in this plane, whereas the
more anterior inferior labrum may be round. The
anterior labrum can be variable in appearance and size,
may be rounded or cleaved, or may even rarely be absent
(Fig. 99-17).100 The posterior labrum is also said typically
to be triangular, but may be rounded, flat or absent.101
The normal bright signal of hyaline cartilage at the base
of the labrum should not be mistaken for a tear or
detachment (Fig. 99-17).102 Linear or globular foci of
increased signal can be observed near the base of the
labrum in normal subjects.103 Magic angle phenomenon
can cause areas of increased signal in the postero-
superior/anteroinferior labrum on proton-density– and
T1-weighted images. This signal should not approach
that of fluid on T2-weighted images.103-105 On MRI, labral
SUPERIOR
scapular spine
deltoid
muscle
humeral
head Infraspinatus
muscle
MEDIAL
teres
minor
tendon teres minor
muscle
F
shape may vary with humeral rotation. Cleaved or
notched101 configurations are normal variants and should
not be mistaken for tears. Labral size, shape, and appear-
ance are also not necessarily bilateral and symmetric.
Partial imaging of the glenohumeral ligaments (see Figs.
99-9 and 99-14)106 may also simulate cleavage planes
or notches in the labrum, or even tears or avulsed
fragments. A similar problem may also occur with partial
imaging of the subscapularis tendon. This may be
most notable in the absence of an effusion when the
glenohumeral ligaments and subscapularis tendons are
closely applied to the anterior labrum. Superiorly, fluid
may be seen in a sublabral recess or foramen (Fig.
99-18).89,107-109 Fluid or contrast beneath the labrum at
the level of the coracoid or below (below the equator or
epiphyseal line) is considered pathologic and indicative
of a tear or detachment. The vacuum phenomenon16 is
where low signal intensity gas is seen intra-articularly
on gradient-recalled echo (GRE) images and should
not be mistaken for a labral tear or cartilage lesion. It is
accentuated with the arm in external rotation and is
located superiorly.
The subscapularis muscle and tendon are also well
visualized in the axial plane (Figs. 99-9 and 99-14). The
subscapularis recess or bursa is identified in the
presence of synovial fluid. This bursa can extend anterior
to the subscapularis tendon, as well as between the
capsule and posterior surface of the tendon (Figs. 99-9
and 99-14). The anterior capsule and its insertion into
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C H A P T E R 99 ■ S HOULDER 3219

spine of
clavicle scapula
ANTERIOR clavicle POSTERIOR ANTERIOR POSTERIOR

scapular
supraspinatus spine
deltoid
m.
coracoid coracoid
deltoid
suprascapular glenoid infraspinatus
nerve SGHL fossa muscle
infraspinatus
muscle subscap t. posterior
subscapularis MGHL pectoralis band, IGHL
muscle
major
subscap
muscke teres minor
anterior muscle
band, IGHL
A B
cephalic v.

supraspinatus
ANTERIOR clavicle POSTERIOR ANTERIOR tendon & muscle acromion POSTERIOR
acromion SGHL
coraco-humeral biceps tendon,
ligament long head
supraspinatus infrapinatus
coracoid transverse
m. tendon &
ligament
humeral muscle
pect. minor head
tendon HH deltoid subscapularis
infraspinatus tendon
m. teres
MGHL
SGHL deltoid minor deltoid
IGHL
biceps tendon,
long head
pect. minor teres minor
m.
C D

ANTERIOR supraspinatus POSTERIOR

tendon

infraspinatus
tendon F I G U R E 99-16
subscaapularis humeral
A-E, Sagittal oblique MRI and MR arthrographic anatomy. Medial
tendon head teres minor to lateral. Short TR/TE images (800/20 ms). IGHL, inferior gleno-
biceps tendon humeral ligament; MGHL, middle glenohumeral ligament; SGHL,
tendon superior glenohumeral ligament; subscap, subscapularis; pect.,
pectoralis; m., muscle; t., tendon. (Prepared by Steven Needell, MD;
deltoid deltoid reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd
ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)

E
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3220 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-17

Labral shape and variation. Axial short TR/TE (800/20 ms) images. A, Triangular appearance of the anterior labrum
(short arrow) and the smaller more round appearance of the posterior labrum (arrowhead). The hyaline articular
cartilage undercutting the posterior labrum is also seen (long arrow). B, Image reveals the small near absent anterior
labrum (arrowhead) and the posterior labrum (arrow) to be larger and more triangular. (Prepared by Steven Needell,
MD; reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott, Williams and
Wilkins, 2003.)

A B

F I G U R E 99-18

Sublabral foramen. A, Axial spoiled gradient-echo image

and B, sagittal oblique MR arthrogram with short TR/TE
BT
image (800/20 ms) and fat suppression. High signal con-
trast outlines a smooth appearing sublabral foramen
(short arrow in A and B). A thick middle glenohumeral
ASL attaches anterosuperiorly (long arrow in B). Note there
SLS
is no sublabral sulcus more superiorly. C, Lateral view
MGHL
illustrates the sublabral foramen. It is anterior and
SLF
inferior to the sublabral sulcus. ASL, anterior superior
labrum; BT, long head of the biceps tendon; MGHL,
middle glenohumeral ligament; SLF, sublabral foramen;
SLS, sublabral sulcus. (Drawn by Salvador Beltran; repro-
duced with permission from Zlatkin MB: MRI of the Shoulder,
2nd ed. Philadelphia, Lippincott, Williams and Wilkins, 2003.)

C
099.qxd 17/6/05 12:55 PM Page 3221
the glenoid margin can be identified on axial images.
It is best seen on long TR/TE images in the presence of
joint fluid, with gradient-echo imaging, or with MR
arthrography. The glenohumeral ligaments may not be
easily separated from the subscapularis tendon on
routine spin-echo axial images but are more easily
identified when an effusion is present. They may also
be better seen with MRI arthrography (Figs. 99-9 and
99-14 to 99-16). On superior sections, the superior
glenohumeral ligament and superior capsule may be
seen inserting into the supraglenoid region, where the
superior labrum and biceps tendon may be identified.
At the midglenoid level the middle glenohumeral
ligament is best identified posterior to the subscapu-
laris tendon and the capsule. At the inferior portion of
the glenoid cavity the inferior glenohumeral ligament
inserts as a thick complex with the inferior capsule
into the labrum. When an effusion is present or with
MR arthrography the three bands of the inferior gleno-
humeral ligament may be identified separately and of
particular importance in the setting of anterior insta-
bility is visualization of the anterior band as it forms
part of the anterior inferior labral-ligamentous complex
(Figs. 99-9 and 99-14 to 99-16).
The biceps brachii functions as a supinator of the
forearm and a flexor of the elbow joint. It is also believed
to be a flexor of the shoulder joint. The long head of the
biceps tendon is seen arising from the supraglenoid
region (see Fig. 99-12). At the level of the superior pole
of the glenoid, four separate attachments of the biceps
tendon may be observed. These include the supraglenoid
tubercle, the posterior superior labrum, the anterior
superior labrum, and an extra-articular attachment to the
lateral edge of the base of the coracoid process. The
biceps labral complex corresponds to the superior one
third of the glenoid. Stoller has described variability in
the pattern of insertion of the long head into the
supraglenoid region as it forms part of the biceps labral
anchor complex.110 As it exits the supraglenoid region
the tendon courses obliquely and anteriorly over the
humeral head. Proximally it may be best seen on coronal
and sagittal oblique images (see Figs. 99-15 and 99-16). It
then courses inferiorly into the intertubercular groove,
where it is well seen on axial sections and appears as a
round signal void (see Fig. 99-14). Its synovial sheath
is seen as a ring of moderate signal intensity,110 which
often contains a small amount of fluid as a normal
finding.111
The tendons of the rotator cuff complex are well seen
on serial coronal oblique images, since this plane courses
parallel to the supraspinatus muscle and tendon (see Fig.
99-15). The infraspinatus and teres minor tendons are
also well delineated in this orientation. The subscapularis
tendon is identified on more anterior coronal oblique
images but is better evaluated on axial images (Fig.
99-14 and 99-15). It may also be delineated on sagittal
oblique images (Fig. 99-16). The subdeltoid bursa is a
potential space and therefore is not visualized as a
separate structure, unless filled with fluid, though on
occasion a thin rim of fluid signal may be seen on fat-
suppressed images in this region.17,74 The subdeltoid
peribursal fat plane112 is seen on short TR/TE and
C H A P T E R 99 ■ S HOULDER 3221
proton-density–weighted sequences, as a high signal
intensity line separating the rotator cuff tendons from
the acromioclavicular joint, acromion, and overlying
deltoid muscle.
On anterior coronal oblique images, the coraco-
clavicular (coronoid and trapezoid) and acromioclavicu-
lar ligaments, as well as the acromioclavicular joint, may
be identified. The anterior acromion can be seen. The
coracoacromial ligament may also be delineated, though
less constantly identified. The anterior edge of the
supraspinatus tendon can be depicted, along with the
long head of the biceps tendon and the subscapularis
muscle and tendon. The rotator interval may be seen on
these sections as well (see Fig. 99-15). The superior and
inferior labrum can be identified in this plane as can the
axillary recess.
The sagittal oblique plane demonstrates the rotator
cuff muscles and tendons in cross section (see Fig.
99-16). The anteroposterior extent of the rotator cuff
tendons can be visualized. The relationship of the
acromion process, the acromioclavicular joint, and the
coracoacromial ligament to the supraspinatus and other
cuff tendons is best depicted. The shape of the anterior
acromion can be discerned on sagittal oblique images.
With fluid in the joint or with MRI arthrography (see
Figs. 99-10 and 99-16), the labrum, capsule, and gleno-
humeral ligaments can be depicted, and in particular the
three limbs of the inferior glenohumeral ligament are
well seen.
The rotator interval may be well evaluated on oblique
sagittal images (see Fig. 99-16). The coracohumeral
ligament is an important landmark on sagittal images,
coursing from the coracoid process into the interval
to blend with the interval capsule. The most proximal
portion of the biceps can be found immediately inferior
and deep to the posterior aspect of the coracohumeral
ligament and interval capsule at the level of the superior
biceps labral anchor complex. The fused coracohumeral
ligament and capsule may be followed posterosuperiorly
to the level of the anterior margin and leading edge of
the supraspinatus.76 The long head of the biceps tendon
should be demonstrated as a smooth low signal intensity
structure which on sequential sagittal images (see Fig.
99-18) can be followed within the rotator interval from
medial to lateral to the bicipital groove, after which axial
images are best for following the tendon from the
proximal bicipital groove (see Fig. 99-14) more distally
along the humeral shaft.76
Although a detailed discussion of anatomic pitfalls
about the glenohumeral joint is beyond the scope of
this chapter, those about the anterosuperior labrum are
so common and give rise to so many difficulties in
interpretation that they warrant separate discussion. The
anterosuperior labrum is the most common site of
normal anatomic variations, with specific variations
described in up to 13.5% of those studied.27,107,109 These
variations in labral attachment occur above the equator
of the glenoid, which occurs at the 3 o’clock position
on the glenoid margin. Below the equator the labrum
should be firmly attached. The anterosuperior labrum is
not attached to the bony glenoid in 8% to 12% of the
population, referred to as a sublabral foramen, also
099.qxd 17/6/05 12:55 PM Page 3222
3222 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
known as a sublabral hole (see Fig. 99-18).113 This finding
is located anterior to the biceps-labral complex.114 A
sublabral recess, also referred to as a sublabral sulcus, is
a recess/synovial reflection between the biceps-labral
complex and the superior margin of the glenoid.113 On
occasion, a sublabral recess can be continuous with a
sublabral foramen.114 In cadaver studies, a sublabral
recess has been demonstrated in up to 73% of shoulders.115
The anterosuperior labrum can also be focally absent,
usually associated with a thickened, cordlike middle
glenohumeral ligament. This entity is referred to as the
Buford complex, believed to be present in approximately
1.5% of patients (Fig. 99-19).114 Pathologic lesions occur-
ring or originating in, or extending into, the antero-
superior labral quadrant can also be distinguished from
normal anatomic variations if they extend below the
level of the coracoid process tip (which helps mark the
equator) towards or into the anteroinferior labrum, or
posteriorly into the posterosuperior quadrant (beyond
the biceps labral anchor).103 Therefore, a Buford complex
should be suspected if the contiguous anteroinferior
F I G U R E 99-19
Buford complex. A, Axial and B, sagittal oblique MR
arthrograms. Short TR/TE images (800/20 ms) with fat
suppression. The labrum is nearly absent antero-
superiorly (arrowhead on A). The thick cordlike middle
glenohumeral ligament is identified partially in A and con-
tinuously in B, attaching to the superior labrum directly
(arrow). C, Lateral view of the Buford complex. Note the
absent anterior superior labrum and the thick, cordlike,
middle glenohumeral ligament which is attaching
anterosuperiorly. BT, long head of the biceps tendon;
MGHL, middle glenohumeral ligament. (Drawn by
Salvador Beltran; reproduced with permission from Zlatkin
MB: MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott,
Williams and Wilkins, 2003.)
and superior labrum appear normal.116 Morphologic
alterations help to distinguish pathologic lesions as well.
MR arthrography will delineate this anatomy to better
advantage and help distinguish variant anatomy from
pathologic lesions.
ROTATOR CUFF DISEASE
Pathophysiology
A variety of different factors are considered to be
important in the etiology of rotator cuff disease and
ultimately rotator cuff tears. The most discussed
mechanisms include rotator cuff impingement beneath
the coracoacromial arch (extrinsic impingement), and
primary degeneration of the cuff. Trauma, overuse
related to occupational and athletic activities, and
glenohumeral joint instability also play a role. Acute and
chronic inflammation such as seen in rheumatoid
arthritis is a less common cause.
099.qxd 17/6/05 12:55 PM Page 3223
A B
F I G U R E 99-20
A, Lateral downsloping (LD) of the anterior acromion as seen on coronal section (arrow). B, Coronal T2-weighted MRI with fat suppression
revealing LD (arrow). Note the corresponding alterations on the bursal surface of the rotator cuff and the thickened subdeltoid bursa filled
with fluid (arrowheads). (Drawn by Salvador Beltran; reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed. Philadelphia,
Lippincott, Williams and Wilkins, 2003.)
Impingement
Rotator cuff impingement may be divided into primary
extrinsic impingement, secondary extrinsic impinge-
ment (secondary to instability), internal impingement
(posterosubglenoid), and subscoracoid impingement.
Primary Extrinsic Impingement
Neer117-120 is most responsible for popularizing this
concept and using this as an aid in clinical management
of patients. Neer119,120 showed that when the shoulder
elevates in its functional arc the rotator cuff and
surrounding soft-tissue structures impinge in the space
beneath the coracoacromial arch. Neer119,120 stated that
95% of rotator cuff tears occur as a result of chronic
impingement beneath this arch. The space below this
arch is defined by the acromion superiorly, the coraco-
acromial ligament superomedially, and the coracoid
process anteriorly. Known sites of impingement in this
arch include the anteroinferior edge of the acromion, the
coracoacromial ligament, and, occasionally, the under-
surface of the acromioclavicular joint.121
Variation in anterior acromion shape also correlates
with cuff tears (see Fig. 99-13).83,122-124 Three types of
acromion have been described, based on their shape. A
type 1 acromion has a flat surface, type 2 has a curved
undersurface, and type 3 has a hooked undersurface. A
fourth type of acromion shape (type 4) has also been
recently described. This has a convex inferior surface.124
As yet no statistical correlation has been found between
this type of acromion and impingement.
The hook-shaped acromion (type 3) has been shown
to have the most significance (see Fig. 99-13).83,122 It has
the highest correlation with rotator cuff pathology and
C H A P T E R 99 ■ S HOULDER 3223
particularly rotator cuff tears. Correlation with surgical
and arthrographic results revealed a 70% to 80%
association of rotator cuff tears with type 3 acromions.83
Lateral or anterior downward sloping of the acromion,
relative to the distal clavicle may also contribute to
impingement and narrowing of the suprapinatus outlet
(Fig. 99-20).125 A low lying acromial position, relative to
the distal clavicle, may decrease the space between the
acromion and the humerus and may predispose certain
individuals to shoulder impingement.
Osteophytes arising from the acromioclavicular joint
and extending inferiorly may play some role in the
impingement process as well. A study by Petersson et
al121 revealed an association between the acromio-
clavicular joint osteophytes and supraspinatus tendon
pathology. Kessel and Watson126 found these changes in
one third of their patients with a “painful arc syndrome”
and lesions of the supraspinatus tendon. In this study
these osteophytes were found to be more common than
anterior subacromial spurs, though they frequently
occur together. Osteoarthritis of the acromioclavicular
joint, however, may be identified on MRI examination in
a large percentage of asymptomatic individuals.111
Spurs on the anterior and inferior aspect of the
acromion are also important.119 These spurs extend from
the anteroinferior surface of the acromion in a medial
and slightly inferior direction toward the coracoid
process. They arise at the acromial attachment of the
coracoacromial ligament. The presence of these spurs is
considered presumptive evidence of shoulder impinge-
ment. Spur size may be strongly associated with the
incidence of a rotator cuff tear.127 Subacromial spurs are
considered to be a more correlative marker of impinge-
ment changes and rotator cuff disease128 than acromio-
clavicular joint osteophytes. Variation in size and
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3224 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
thickness of the coracoacromial ligament, especially
the wide portion inferior to the acromion, may be an
additional factor in narrowing the subacromial space and
thus causing attritional changes of the rotator cuff.129
An unfused apophysis of the anterior acromion,
known as the os acromiale, may contribute to shoulder
impingement.130-132 These normally fuse by 25 years of
age. Fusion failure may occur in 8% of the population and
thus form an os acromiale.133 The os acromiale may cause
impingement because, if it is unstable, it may be pulled
inferiorly during abduction by the deltoid, which
attaches here. In addition, hypertrophy and spurring may
develop at the junction of the os acromiale and the more
posterior aspect of the acromion along its undersurface,
and may contribute to impingement and subsequent
rotator cuff tears in this manner.134
The clinical syndrome of impingement was outlined
by Neer.119 He described the technique of anterior
acromioplasty to relieve the symptoms of impingement.
Three progressive stages of impingement lesions were
described. This was based on the age of the patient, the
type of activity that presumably led to the injury, and the
pathologic findings. Stage 1 typically results from
excessive overhead use such as in sports. It usually
occurs in patients younger than 25 years of age, but may
occur at any age. Histologically, edema and hemorrhage
are said to be present in the rotator cuff tendons at this
stage. If treated conservatively, this phase of the disease
is usually reversible and these patients may return to
normal function.
Stage 2 disease consists of fibrosis and thickening of
the rotator cuff tendons as well as the subacromial-
subdeltoid bursa. It occurs in patients between 25 to
40 years of age and is less common than stage 1. The
shoulder will usually become symptomatic after
vigorous overhead use such as in throwing sports.
Traditionally, surgery is considered in these patients
when a conservative approach to therapy has failed. The
procedure at this stage is removal of the thickened
subacromial bursa and dividing the coracoacromial
ligament. According to Neer,119,120 anterior acromio-
plasty in this group of patients who are younger than
40 years old should not be performed unless overhang
and prominence of the undersurface of the anterior
acromion is present.
Stage 3 results from further impingement wear. At this
stage incomplete (3A) or complete tears (3B) of the
rotator cuff are present. These lesions are most common
in patients older than 40 years of age. Lesions of the
biceps tendon are usually present, though true tears of
the biceps tendon are much less common than the
associated cuff tears. Secondary bone changes are very
common. Acromioplasty and cuff repair are often
required.
Secondary Extrinsic Impingement (Impingement
Associated with Instability)
Fu et al134 subdivided impingement syndromes into two
major categories: primary extrinsic impingement which
occurs in nonathletic persons and is related to
alterations in the coracoaromial arch as discussed earlier;
and secondary impingement occurring mainly in
athletes involved in sports requiring overhead motion of
the arm and which has a relationship to glenohumeral
joint instability.135,136 These patients may develop
symptoms without any abnormality of the bony anatomy
of the coracoacromial arch. These patients usually
have less advanced rotator cuff pathology, including
tendinosis or partial or very small rotator cuff tears.136
This distinction is important, since therapy should be
directed to the underlying instability. Conservative
treatment is aimed at strengthening the rotator cuff and
scapular rotators. Throwing athletes with glenohumeral
instability and secondary impingement that do not
respond to conservative treatment may be treated with
an anterior capsular labral reconstruction. In the less
common situation where alterations of the bony
coracoacromial arch may also be identified (mixed
pathology), then subacromial decompression may be
necessary in addition to anterior stabilization.
Posterosubglenoid (Internal) Impingement
This is impingement of the rotator cuff on the
posterosuperior portion of the glenoid in throwing
athletes.38,137-144 This is also known as internal
impingement. This particular type of impingement
occurs during the late cocking phase of throwing
with abnormal contact between the posterosuperior
portion of the glenoid rim and the undersurface of
the rotator cuff, and is thought to occur at the extremes
of abduction and external rotation. It has also been
recognized in nonathletes who frequently rotate the
shoulder into the extremes of abduction and external
rotation.139,145
A triad of findings will be present including injury to
the rotator cuff undersurface at the junction of the
infraspinatus and supraspinatus tendons, degenerative
tearing of the posterosuperior glenoid labrum, as well as
subcortical cysts and chondral lesions in the postero-
superior glenoid and humerus due to repetitive impac-
tion. There may in addition be an injury to the inferior
glenohumeral ligament and anterior inferior labrum.
Subcoracoid Impingement
Impingement beneath the coracoid process relates to
encroachment of the subscapularis tendon insertion on
the lesser tuberosity,146-148 secondary to narrowing of
this space between the coracoid process and the humeral
head. Developmental enlargement of the coracoid pro-
cess that projects more laterally may be the underlying
cause.
Subcoracoid impingement may occur when the
distance between the coracoid and lesser tuberosity
measures less than 11 mm, with the arm positioned in
maximal internal rotation.15
Other Causes
These may include such entities as supraspinatus muscle
hypertrophy in athletes who perform repetitive over-
head activity, such as swimmers. In these patients, the
099.qxd 17/6/05 12:55 PM Page 3225
enlarged supraspinatus muscle belly may seem to be
deformed beneath the acromioclavicular joint on
coronal oblique MR images.149 Impingement may also
occur related to prominent healed callus from a greater
tuberosity fracture.
Primary Rotator Cuff Degeneration
(Intrinsic Causes)
There are other theories on the etiology of rotator cuff
tears and many who disagree with the predominant or
exclusive role of impingement in the development of
cuff tears. Codman150,151 suggested that degenerative
changes within the cuff itself lead to tears. This may have
a vascular or ischemic basis. Codman150,151 described
a critical portion in the rotator cuff at the distal
supraspinatus tendon approximately 1 cm medial to its
insertion into the greater tuberosity. Codman150-152
described the pattern of degenerative cuff failure as a
“rim rent” in which the deep surface of the cuff is torn
at its attachment to the tuberosity. He stated that
these tears tend to begin on the deep surface and
then extend outward until they become full-thickness
defects. He pointed out that it would be hard to explain
this on the basis of erosion from contact with the
acromion process.
Uthoff et al153-155 found that most rotator cuff
tears begin from the articular side. They indicated that if
rotator cuff tears arose primarily from extrinsic
impingement, then the majority of rotator cuff tears
should begin from the bursal side. On the basis of this
they considered that rotator cuff tears are therefore
degenerative in origin and nature and that extrinsic
causes therefore play a secondary role. Ozaki et al156
have shown in cadavers that the majority of pathologic
changes of the undersurface of the acromion occurred in
specimens in which the cuff tear was incomplete and on
the bursal side of the cuff.
The critical portion in the rotator cuff has been
described as “the critical zone.” This region is said to be
a watershed area, occurring between osseous and ten-
dinous vessels supplying the rotator cuff tendons.153,157
The histologic pattern of age-related degeneration in
the tendon reveals changes in cell arrangement, calcium
deposition, fibrinoid thickening, fatty degeneration,
necrosis, and rents. There is an alteration in the pattern
of collagen fibers in such patients, with transforma-
tion from type II to fibrovascular-containing type III
collagen.158,159
In contrast, intraoperative laser Doppler flowmetry
has also been used to assess the rotator cuff tendon
vascularity in symptomatic patients.160 These studies
were considered to support impingement as a mech-
anism of rotator cuff pathology. Particularly in patients
with intact tendons and tendinosis but also in patients
with partial and complete tears, increased vascularity
was found in the region of the critical zone. Brooks
et al161 also carried out perfusion studies which they
considered did not support an ischemic zone in the
distal anterior supraspinatus tendon. They concluded
that factors other than vascularity are important in the
pathogenesis of supraspinatus rupture.
C H A P T E R 99 ■ S HOULDER 3225
Budoff et al162 argued that most patients with rotator
cuff abnormalities have as their primary underlying
etiology intrinsic, rather than extrinsic, impingement,
which they believe occurs secondary to rotator cuff
failure. They stated that the suprapinatus, since it is a
small and relatively weak muscle, is in a key position and
is therefore susceptible to overuse and injury. When
eccentric tensile overload occurs at a rate greater than
the ability of the cuff to repair itself, injury occurs,
resulting in weakness of the musculotendinous rotator
cuff unit. Trauma to the shoulder may initiate the process
as well, and a weak, fatigued or injured rotator cuff is
unable to oppose the superior pull of the deltoid
effectively, which is then unable to keep the humeral
head centered on the glenoid during elevation of the
arm, causing it to elevate, which then functionally
narrows the subacromial space. Continued dysfunction
of the rotator cuff and further superior migration of the
humeral head cause the greater tuberosity and rotator
cuff to abut against the undersurface of the acromion
and the coracoacromial ligament, leading to signs of
secondary extrinsic impingement. These authors believe
that changes to the coracoacromial ligament and the
undersurface of the anterior acromion are secondary
processes, and since they do not occur in many patients,
these structures should be preserved if their anatomy is
not altered. They believe that these structures play an
important role as passive stabilizers against superior
migration of the humeral head, and therefore should not
be sacrificed. These authors therefore recommend
debridement of the degenerated cuff tissue arthroscop-
ically, and resection only of clearly identified excres-
cences. They do not perform a complete acromioplasty
and do not remove the coracoacromial ligament.
Trauma
Trauma is considered to play a secondary role in the
etiology of rotator cuff tears.119,120 Little force may be
needed to tear a tendon that is already degenerated by
long-standing impingement wear, perhaps related to
underlying tendinosis and repeated episodes of peri-
tendinous inflammation. The trauma from a fall or
dislocation may, therefore, complete or enlarge a pre-
existent small or incomplete tear, or tear an already
degenerated tendon.
Notwithstanding the above, a tear may occur
following an anterior dislocation of the shoulder, usually
in an older patient in whom a cuff rupture occurs rather
than an injury to the glenoid labrum and/or shoulder
capsule. Studies show that a cuff tear may occur in 14%
to 63% of patients with acute anterior dislocations.
The incidence will be higher in older patients.163-166 The
supraspinatus tendon may tear with variable degrees of
infraspinatus involvement.
Traumatic tears of the subscapularis tendon may
occur due to traumatic hyperextension or external
rotation of the abducted arm.167 Concomitant biceps
tendon pathologic conditions include subluxation,
dislocation, or rupture. Isolated ruptures of the sub-
scapularis may also occur with anterior dislocations,
again predominantly in male patients older than 40.164,168
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3226 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
Avulsive fractures of the lesser tuberosity at the site
of insertion of the subscapularis may occur in elderly
women and men.With a posterior dislocation there may
be disruption of the infraspinatus or teres minor
tendons.169 Superior dislocations of the humeral head
may also result in cuff rupture as the humeral head is
driven upward acutely through the cuff.
A cuff tear may also arise following a dislocation
when the greater tuberosity is fractured. It may also
develop following an avulsion fracture of the greater
tuberosity. Posterior dislocations may also result in a
fracture of the lesser tuberosity, in which case a tear of
the subscapularis tendon may result. Although a non-
displaced greater tuberosity fracture may result in injury
to the cuff, recent evidence with MRI170,171 indicates that
this may more often result in a tendon contusion or
intact cuff, rather than a tear, and the pain may more
commonly be related to the bony injury.
Classification, Location, and Incidence
of Rotator Cuff Tears
A full-thickness rotator cuff tear extends from the
articular surface to the bursal surface of the cuff. A
complete tear is one in which the whole thickness of
the rotator cuff and capsule are torn, resulting in direct
communication between the subdeltoid bursa and the
joint cavity.172 In contrast, partial-thickness tears (Fig.
99-21) involve only one surface of the cuff, either the
inferior or superficial surface, or only the midsubstance
of the cuff. Tears of the inferior surface are also referred
to as deep or articular surface tears, those of the
midsubstance as intrasubstance tears, and those of
the superficial surface as superior or bursal surface
tears. Retraction of tendinous fibers from the greater
tuberosity may also be considered a partial tear.96
Partial tears have been classified by Ellman173 as
follows: grade 1 (low grade) are less than 3 mm deep and
only the capsule or superficial fibers are involved; grade
A B
F I G U R E 99-21
Classification of partial tears by location. A, Articular surface partial tear; B, bursal surface partial tear; and C, intrasubstance
(interstitial) partial tear. (Drawn by Salvador Beltran; reproduced with permission from Zlatkin MB: MRI of the Shoulder, 2nd ed.
Philadelphia, Lippincott, Williams and Wilkins, 2003.)
2 (intermediate) are 3 to 6 mm deep and less than 50%
of the cuff thickness is involved; and grade 3 (high grade
or deep) greater than 6 mm, in which more than 50% of
the cuff thickness is involved.
Complete cuff tears can be classified by size. Small
tears are less than 1 cm, medium tears are less than 3 cm,
large tears are 3 to 5 cm, and massive tears are greater
than 5 cm.174 Ellman175 proposed that the area of a tear
be measured in square centimeters using the base of the
tear along the former insertion site times the depth of
the muscle retraction. The size of the rotator cuff tear in
both anterior posterior and mediolateral dimensions is a
very important prognostic factor in determining surgical
outcome.176
Most partial and small full-thickness rotator cuff tears
are centered in the anterior half of the supraspinatus.177
Supraspinatus tears begin on the deep surface anteriorly
and distally at the greater tuberosity insertion, near the
biceps tendon, and then extend outward until they
become full-thickness defects. Once in the supraspinatus
the defects then propagate posteriorly and medially
through the remaining portions of the supraspinatus and
then into the infraspinatus. This then puts progressive
stress on the biceps tendon. Changes in the biceps
tendon may initially be of a less severe degree, and may
only consist of tendinosis, but it may eventually rupture,
especially in chronic defects. The defect may then
propagate across the bicipital groove to involve the
subscapularis tendon, starting at the top of the lesser
tuberosity and extending inferiorly.
Involvement of the subscapularis tendon may occur
with larger tears and anterior tears. In this case it may
often involve the superior articular surface fibers and the
rotator interval capsule. It may also be involved in
subcoracoid impingement. Acute ruptures of the
subscapularis can occur with severe trauma, or in elderly
patients with recurrent anterior dislocations. As the
lesions propagate anteriorly into the subscapularis
they may result in medial dislocation of the biceps
tendon.75,167,168,178-182
C
099.qxd 17/6/05 12:55 PM Page 3227
Isolated infraspinatus full-thickness tears are
uncommon. They can occur in the spectrum of posterior
superior (internal) subglenoid impingement or with
severe trauma with posterior dislocation. Partial tears
occurring at the junction of the posterior supraspinatus
and anterior infraspinatus can occur in overhead
throwing athletes in association with posterior superior
(internal) subglenoid impingement.141 Tears of the teres
minor tendon are distinctly rare, even in the setting of
massive tears, though partial tears of the superior aspect
of the teres minor have been reported in a series of
massive, irreparable, rotator cuff tears.183 They may occur
with trauma, in association with posterior capsular
rupture as well as infraspinatus tendon tears, or in the
setting of a posterior dislocation. In this situation, teres
minor muscle and capsular injuries may occur without
the typical reverse Bankart lesion.184
With progressive disruption of the rotator cuff
tendons, the humeral head can then rise under the pull
of the deltoid muscle. This then leads to abrasion of
the humeral head articular cartilage against the coraco-
acromial arch, causing subacromial impingement that in
time erodes the anterior portion of the acromion and the
acromioclavicular joint. There are also nutritional factors
related to the rotator cuff tear that cause atrophy of the
glenohumeral articular cartilage and osteoporosis of the
subchondral bone of the humeral head. Eventually, the
soft, atrophic head collapses, producing the complete
syndrome of rotator cuff tear arthropathy.185,186
One other factor that is important when evaluating
rotator cuff tears is the assessment of the status of the
torn rotator cuff tendon edges. On imaging examinations
as well as at surgery the appearance of the torn edges
may be classified as good, fair or poor.187,188 The status of
the rotator cuff musculature with regard to the degree of
atrophy, as well as fatty infiltration, can be also be
quantified in a relative manner as mild, moderate, or
severe.187,188 Another system classifies both atrophy and
fatty infiltration. Goutallier et al189,190 graded muscular
fatty degeneration into five stages in patients with
rotator cuff tears.
Magnetic Resonance Imaging
Bone Changes Associated with
Extrinsic Impingement
The most common secondary bone changes that have
been described in association with extrinsic impinge-
ment include acromioclavicular joint osteophytes,
subacromial spur formation, and cysts and sclerosis in
the greater tuberosity.
Subacromial spurs are less common but are more
correlative of rotator cuff disease than acromioclavicular
osteoarthrosis (Fig. 99-22).111 They are the most specific
finding on MR examination for shoulder impingement.191
Small subacromial spurs may appear on MRI exam-
ination as a signal void that projects from the acromion
tip in a medial and inferior direction, and may be
surrounded by a rim of signal void representing cortical
bone,192 and must be distinguished from the insertion of
C H A P T E R 99 ■ S HOULDER 3227
the coracoacromial ligament or the deltoid insertion.99
The inferior tendon slip of the deltoid inserts on the
inferolateral acromion, coracoacromial ligament, and
inferomedial acromion.99 Larger spurs frequently contain
marrow and thus have brighter signal.193 The anterior
and inferior location of the spurs are often best shown
on sagittal oblique images. Larger spurs may be evident
on coronal oblique images.
Degenerative osteophytes of the acromioclavicular
joint have similar appearances. They may be inferiorly
projecting. These osteophytes of the acromioclavicular
joint may precede the presence of anterior acromial
spurs. Hypertrophy and callus formation of the
acromioclavicular joint capsule may also be visualized,
which appears as a rounded mass of medium signal
intensity surrounding the joint, which often projects
inferiorly194-196 and may encroach on the bursal surface
of the musculotendinous junction of the supraspinatus.
The relationship of the acromioclavicular joint arthrosis
to the subacromial space and bursal surface of the cuff
are best seen on the sagittal oblique and coronal oblique
sequences (see Figs. 99-15 to 99-18). Fluid may be seen
in the acromioclavicular joint, especially on fat-saturated
images, and there may also be increased signal on these
fat-saturated images in the bony margins of this joint. The
significance of fluid within the acromioclavicular joint
has also been debated, however.195,197,198 It is speculated
that marginal edema in the bones about the acromio-
clavicular joint may be a marker of this joint as a site or
source of pain in patients with these findings. Edema
in the distal clavicle alone may be stress related and
may be particularly common in athletes such as weight
lifters, throwers, and swimmers (Fig. 99-23). Low signal
intensity sclerosis, erosions, and subchondral cysts are
also identified on MR images in patients with acromio-
clavicular joint arthrosis.
F I G U R E 99-22
Sub-acromial spur. Coronal oblique T1-weighted image. Note the mature
appearing subacromial spur (arrow).
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3228 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-23

Acromioclavicular joint osteoarthritis. A, Coronal oblique and B, sagittal oblique fast spin-echo T2-weighted MR
images with fat suppression. The acromioclavicular joint shows advanced degenerative changes with inferiorly
projecting spurs, capsular hypertrophy, and marginal edema (arrows).

The three types of acromion shape described for plain

radiographic examination can be adapted for MRI (Figs.
99-13 and 99-24). Type 1 has a flat or straight inferior
surface. Type 2 demonstrates a smooth curved inferior
surface that approximately parallels the superior
humeral head in the sagittal oblique plane. Type 3 has an
inferiorly curved or hook shape on sagittal images
(Fig. 99-24). Type 3 acromions are statistically associated
with an increased incidence of rotator cuff tears. Studies
that have used sagittal oblique MRI to determine the
presence of hook-shaped anterior acromions have also
found an association with clinical impingement and
rotator cuff tears.199 A type 4 acromion can be appre-
ciated on MR examination when the acromion appears
convex near its distal end.124 Peh et al85 found that the
apparent acromial shape is sensitive to the minor
changes in the MR section viewed. More medial sections
closer to the acromioclavicular joint may falsely
produce the appearance of a hooked anterior acromion, F I G U R E 99-24
which has a flat appearance on more peripheral sagittal
oblique images. Type 3 acromion. Sagittal oblique fast-spin echo T2-weighted MR image
Lateral or anterior downward sloping of the with fat suppression. Note the hook-shaped, type 3 acromion (white
acromion, or a low lying acromion, relative to the distal arrow). A thickened coracoacromial ligament is also present (black arrow).
clavicle may contribute to impingement and narrowing
of the suprapinatus outlet, and can be discerned on MRI
images. Impingement related to lateral downsloping of
the anterior acromion may cause impingement of the downsloping is best seen on sagittal MR images and
mid portion of the supraspinatus tendon. It may cause lateral downsloping on coronal MR images. Anterior
impingement on the superior aspect of the subscapularis downsloping of the acromion is present when the
tendon.125,200 This type of acromial position may also be anterior inferior cortex of the acromion is more infe-
associated with lateral supraspinatus injury near the riorly located relative to the posterior cortex on sagittal
greater tuberosity insertion, especially in patients who oblique images. Lateral downsloping is identified when
perform forceful abduction of the shoulder.196 Anterior the inferior surface of the distal acromion is inferior or
099.qxd 17/6/05 12:55 PM Page 3229
A B
F I G U R E 99-25
Os acromiale. A, On this superior axial section the os acromiale is well seen (arrow). Marginal edema is present.
B, Posterior coronal oblique images may also identify the presence of the os acromiale (arrow). Note the pseudo
acromioclavicular joint, more posterior in location.
caudally located, relative to the inferior surface of the
more proximal aspect of the acromion, adjacent to the
acromioclavicular joint (see Fig. 99-20).
Thickening of the coracoacoromial ligament may
contribute to narrowing of the supraspinatus outlet and
is best seen on sagittal oblique images (see Fig. 99-24).
This includes assessment of its size and whether the
thickening is smooth or irregular.129,192,201-203
The os acromiale is identified best on superior axial
sections that demonstrate the entire acromion (Fig.
99-25A). The synchondrosis should not be mistaken for
the subjacent acromioclavicular joint. When superior
axial sections are not available this pattern of mimicking
the acromioclavicular joint on sagittal and coronal
oblique images may also be used to help identify the
presence of the os acromiale (Fig. 99-25B).130,131,204-206
Increased signal on either side of the fusion defect may
be seen on both STIR and fat-suppressed T2-weighted
fast spin-echo sequences (Fig. 99-25A). This hyper-
intensity may correlate with degenerative changes or
instability of the os acromiale. It is important to identify
the os acromiale because removal of the acromion distal
to the synchrondrosis at the time of acromioplasty may
further destabilize the synchondrosis and allow for even
greater mobility of the os acromiale after surgery and
worsening of the impingment.204
Hypertrophic changes or flattening and sclerosis may
occur in the region of the greater tuberosity in patients
with impingement. This is likely as noted above to be
due to traumatization of the greater tuberosity on the
undersurface of the acromion during abduction. These
may be appreciated on MR examination as areas of
cortical thickening or prominent low signal in the region
of the greater tuberosity.149
C H A P T E R 99 ■ S HOULDER 3229
Humeral head or greater tuberosity cysts have been
associated with shoulder impingement. This is a very
common finding on MR examination. More recently
these cysts, which can become quite large, have been
considered to be nonspecific and are as well correlated
with increasing age as they are with alterations in the
rotator cuff, reflective of impingement.111 These cysts
are often posteriorly located at the greater tuberosity or
at its junction with the humeral head near the capsular
insertion. Cysts may also occur more superiorly or ante-
riorly as well.149
Tendon Lesions
Tendinosis
A variety of terms may be used to describe the injured
tendon in the absence of a tendon defect. The term most
commonly used in the past was tendonitis. Most authors
prefer the term tendinosis or tendinopathy as the
pathologic changes found within such tendons most
often do not include inflammation,207-209 except in the
peritendinous tissues. The MRI findings of tendinosis
(Fig. 99-26) are moderate increase in signal intensity
within the tendon on short TR/TE and proton-density
images, oriented along the long axis of the tendon, which
may be homogeneous (focal, diffuse or bandlike)96 or
inhomogeneous, and which fades or is absent on long
TR/TE (T2-weighted images) whether obtained with
conventional96,187,188,210 or fast spin-echo imaging
sequences without fat suppression. Fat-suppressed
conventional or fast spin-echo T2-weighted sequences, or
STIR imaging sequences, may make this signal more
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3230 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-26

Tendinosis. A, Coronal oblique T1-weighted image. Diffuse increased signal in the supraspinatus tendon is present
(arrow). The articular and bursal surfaces of the tendon are intact. B, Coronal oblique fast spin-echo proton-
density–weighted sequence with fat suppression. Note the relative increase in tendon signal, which can be seen when
fat suppression is present but does not approach fluid signal (arrow).

A B
F I G U R E 99-27

Tendinosis. Articular surface fraying/fibrillation. MR arthrography. A, Coronal oblique fast spin-echo T2-weighted
sequence with fat suppression. Moderate tendinosis is seen in the supraspinatus tendon and there is undersurface
fraying and irregularity (arrows). A small amount of fluid is seen in the subdeltoid bursa, likely reflective of bursal
inflammation (arrowhead). B, Coronal oblique T1-weighted MR arthrogram with fat suppression outlines the
undersurface fraying and irregularity (arrows), but no focal tendon defect is seen.

conspicuous and should be distinguished from true fluid
signal as seen in a rotator cuff tear (see Fig. 99-26).188
Tendon thickening may be present, and increased and
more diffuse thickening may be associated with more
advanced tendinosis. It is proposed that persistence of
increased signal within the tendon on images with T2
weighting, but less intense than fluid signal, may indicate
more advanced tendinosis, related to a greater degree of
collagen breakdown in the tendon.211
Fat-saturated T2-weighted fast spin-echo images are
more sensitive to the presence of fluid in the subdeltoid
bursa (Figs. 99-27 and 99-28). With the use of these
sequences, identifying fluid in the subdeltoid bursa
region is a more common correlate of disease at this
stage than previously thought.187,188 When evident, fluid
is considered to be indicative of associated subdeltoid
bursal inflammation. Persistent low signal intensity in a
thickened subacromial subdeltoid bursa on imaging
sequences with both T1 and T2 contrast has also been
described96 and is said to indicate proliferative chronic
subdeltoid bursitis, but this appearance is more difficult
to discern on MRI studies.
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C H A P T E R 99 ■ S HOULDER 3231

A B
F I G U R E 99-28

Tendinosis. Bursal surface fraying/fibrillation. A, Coronal oblique fast spin-echo proton-density–weighted image and
B, fast spin-echo T2-weighted sequence with fat suppression. Moderate/severe tendinosis is seen in the supra-
spinatus tendon and there is bursal surface fraying and irregularity (arrows). A moderate amount of fluid is seen in the
subdeltoid bursa (arrowheads), reflective of bursal inflammation.

A B
F I G U R E 99-29

Tendinosis. MR arthrography. A, Coronal oblique fast spin-echo proton-density–weighted image. Diffuse increased
signal in the supraspinatus tendon is noted (arrow). The articular and bursal surfaces of the tendon are smooth.
B, Coronal oblique T1-weighted MR arthrogram with fat suppression. No contrast-filled tendon defect is seen
(arrow).

The arthroscopic findings in patients with these MRI
findings are hyperemia of the tendon surface and bursal
scarring and inflammation.187 Biopsy of the tendon in
patients with MRI findings consistent with tendinosis
has been carried out in a small number of patients and
has shown mucoid degenerative changes and some
inflammation.212 Histologic sectioning in cadavers with
similar MRI findings revealed eosinophilic, mucoid, and
fibrillary degeneration.94
MR arthrography (Fig. 99-29) may confirm the
integrity of the articular surface of the cuff. In patients
with tendinosis the articular surface should be linear in
contour and low in signal intensity.29
Anzilotti et al213 described a subset of young patients
(<35 years) with acute, post-traumatic insults to the rota-
tor cuff which mimic the signal intensity changes of ten-
dinosis. Patients had signal intensity that was similar to
tendinosis, but was localized more in atypical locations
of the supraspinatus tendon and was associated with bone
bruise, suggesting the possibility of post-traumatic strain.
Tendons with a similar MRI appearance to tendinosis
have been detected in asymptomatic individuals.97,214,215
They should be distinguished from advanced rotator
disease and rotator cuff tears as they are not associated
with morphologic alterations and do not brighten like
fluid on long TR/TE images.
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3232 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-30

Articular surface partial tears. A, Coronal oblique T2-weighted image. A high-grade partial tear of the supraspinatus
tendon undersurface is seen. Note the focal tendon defect outlined by the fluid signal (arrow). B, Sagittal oblique fast
spin-echo T2-weighted image with fat suppression in another patient. A deep articular surface defect is again
identified. The addition of fat suppression increases the conspicuity of the lesion (arrow).

Other MRI changes beyond tendinosis, not indicative
of either a partial or complete tear but considered
abnormal, include tendon thinning or irregularity of the
tendon surface (see Figs. 99.27 and 99.28). MR arthrog-
raphy will outline those findings that occur on the
articular side (see Fig. 99-27B). Such irregularities in con-
tour and signal intensity indicate fraying of the super-
ficial fibers of the tendon. At arthroscopy the tendon
surface is described as showing “fraying, roughening or
degeneration.”158,187 On the bursal side of the tendon,
T2-weighted images, especially with fat suppression,
will show some fluid in the subdeltoid bursa that likely
reflects bursal and peribursal inflammation. These
findings may be reflective of the wear and tear of
impingement. The distinction between this stage of
disease and early partial-thickness tears may be difficult
to define both by MRI and at arthroscopy, though by
definition173 in order to describe a partial tear a discrete
tendon defect should be seen.
Partial Tears
Using MRI the diagnosis of partial tears is less sensitive
and accurate than for complete tears.3,6,8,96,187,188,216-220 A
partial tear can be diagnosed when there is a defect that
extends to one surface only, either the articular surface
(Fig. 99-30), which is more common, or the bursal
surface (Fig. 99-31), or is within the tendon substance
(intrasubstance or interstitial), and that shows increased
signal on long TR/TE images, or on other imaging
sequences with T2 contrast.When the increased signal is
that of fluid the diagnosis can be made with confidence.
Tears of the bursal surface and of the undersurface will
be perpendicular to the long axis of the tendon on
coronal oblique imaging sequences, whereas those in the
tendon substance are parallel to the long axis of the
tendon (Fig. 99-32).
Some partial tears may be partially healed or quite
small and, therefore, the signal increase may not be as
strong. In such situations they may be difficult to
distinguish from tendinosis. Fat saturation or STIR images
may help (see Figs. 99-30 and 99-32).3,6,210,217,221
T2-weighted fast spin-echo techniques with fat satura-
tion can obtain this type of contrast in a more efficient
manner. STIR imaging has also been suggested to
increase diagnostic performance as well. Partial tears
may less commonly be manifested by significant loss of
tendon thickness. T1-weighted images with fat satura-
tion after the intra-articular injection of gadolinium
diethylenetriamine pentetate (Gd-DTPA) are of value in
the diagnosis of partial tears of the articular surface of
the tendon (Fig. 99-33).19,23,26,32,35,39,222 In this situation
MR arthrography maximizes anatomic resolution and
diagnostic confidence. Partial-thickness tears occur and
begin commonly along the undersurface of the antero-
distal insertion of the cuff near the “critical zone,” and
therefore evaluating this region of the cuff undersurface
with MR arthrography is of considerable importance in
the differentiation of a normal cuff and cuff tendino-
sis from one with a partial tear. On MR arthrography a
partial-thickness tear is diagnosed when contrast extends
in a focal manner into a tendon defect,but does not extend
into the subacromial subdeltoid bursa. MR arthrography
is also very effective at depicting the extent of morphol-
ogic alterations and their depth of involvement by show-
ing contrast imbibition and the depth of loss of tendon
thickness (Fig. 99.33). This is again helpful in distinguish-
ing these alterations from those associated with tendi-
nosis and tendon surface degeneration.
Partial tears associated with posterosuperior sub-
glenoid impingement (Fig. 99-34) may have areas of
delamination of the rotator cuff undersurface and loose
flaps of cuff tissue may be seen on the cuff undersurface.
These partial tears which commonly occur posteriorly at
the junction of the suprapsinatus and infraspinatus are
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C H A P T E R 99 ■ S HOULDER 3233

A B
F I G U R E 99-31

Bursal surface partial tears. A, Coronal oblique T2-weighted image. An intermediate-grade partial tear of the
supraspinatus tendon superior surface is seen. A focal tendon defect outlined by fluid signal is seen (outlined by short
and long arrows). B, Sagittal oblique fast spin-echo T2-weighted image with fat suppression. Note the fluid signal
outlining a high-grade bursal surface partial tear of the supraspinatus tendon (arrows).

sometimes referred to as posterior interval tears.141,143,223
MR arthrography and the arm placed in ABER posi-
tion39,141,223 may be useful in such patients. This position
also allows better depiction of the other lesions in the
spectrum of this process, including the osteochondral
compression fracture of the posterosuperior humeral
head, degenerative fraying or tear of the posterosuperior
glenoid labrum and alterations of the subjacent glenoid,
and the less common involvement of the inferior
glenohumeral ligament and anterior inferior labrum.
Intrasubstance partial tears are difficult to confirm
with either surgery or arthroscopy, unless the tendon is
incised. This diagnosis is considered on MR images
when fluid signal is present on long TR/TE images in the
substance of the tendon, i.e., parallel to the long axis of
the tendon, and not extending to either the bursal or
articular surface (see Fig. 99-32). Acute tendonitis or
tendon contusions after trauma can theoretically have a
similar pattern of increased signal as well. Combinations
of partial tears may also be seen.

F I G U R E 99-32 F I G U R E 99-33

Intrasubstance partial tears. Coronal oblique fast spin-echo T2-weighted Partial tears. Coronal oblique T1-weighted MR arthrogram with fat
image with fat saturation. Longitudinal increased signal in the tendon saturation. A high-grade articular surface partial-thickness tear of the
substance approaching that of fluid is seen (arrow). The signal is oriented supraspinatus tendon is seen (arrow). MR arthrography clearly outlines the
parallel to the tendon. extent and depth of the tendon defect.
099.qxd 17/6/05 12:56 PM Page 3234
3234 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-34
Subglenoid impingement. Axial oblique T1-weighted MR arthrogram with
fat saturation performed with the patient in the abduction and external
rotation (ABER) position. Note the flaplike areas of undersurface partial
tearing of the supraspinatus tendon (white arrow). There is fraying of the
posterosuperior labrum (black arrow). Note the cystic areas of the
posterosuperior humeral head (arrowheads).
Fluid in the subdeltoid bursa may commonly be
identified in bursal-side partial-thickness tears and may
make it easier to assess the size and depth of these
tears.82 Bursal-side partial tears cannot be identified with
MR arthrography from the articular side. Preliminary
work with MR bursography has the potential to improve
the accuracy for diagnosis of bursal-side partial tears, but
as yet has not been used very often in clinical practice.
Retraction of tendinous fibers from the distal
insertion into the greater tuberosity may also be
considered a partial tear (Fig. 99-35). This may occur in
the throwing athlete, specifically baseball players.224
These lesions appear as small regions of high signal
intensity on long TR/TE images in this location, with
associated bony defects on the greater tuberosity. Partial
tears of differing size and nature may coexist in different
portions of the rotator cuff or at the posterior margin of
a larger tear.
Full-Thickness Tears
This diagnosis is made with the visualization of a
complete defect in the tendon, extending from the artic-
ular to the bursal surface of the tendon, most commonly
involving the supraspinatus tendon.3,4,6,82,96,187,188,217,
220,225-229
The defects in the rotator cuff are filled with
fluid, granulation tissue, or hypertrophied synovium,
and therefore in the majority of cases (80% or greater)
with a cuff defect, fluid-like signal is present within
the defect on long TR/TE images,229 which can be
F I G U R E 99-35
Insertional partial tear. Coronal oblique fast spin-echo proton-
density–weighted image with fat saturation. A fluid-filled insertional defect
is seen at the supraspinatus tendon insertion into the greater tuberosity
(arrow).
made more conspicuous with the use of fast spin-echo
sequences with fat suppression or fast inversion recov-
ery sequences (STIR). The presence of a tendon defect
filled with fluid is the most direct and definite sign of a
rotator cuff tear.
In the presence of a full-thickness tear, especially
larger tears, tendon retraction may be present and the
supraspinatus may take on a more globular configuration
(Fig. 99-36).229 The location of the musculotendinous
junction can vary even in asymptomatic individuals and
depends on the position of the arm during the MR
examination. Therefore, the use of retraction of the
musculotendinous junction alone as a direct sign of a
rotator cuff tear in the absence of a clear tendon
defect is not recommended. In large to massive tears the
tendon may retract as far as the medial glenoid margin
(Fig. 99-37).
MR arthrography is most helpful in distinguishing
small from partial tears and tendinosis, and in assessing
the reparability of the cuff and the postoperative
prognosis in larger cuff tears. MR arthrography is helpful
in determining the size and location of cuff tears and in
assessing the status of the torn tendon edges (Fig. 99-38).
The diagnosis of a full-thickness rotator cuff tear on MR
arthrography is made when contrast extends through a
defect in the tendon from the cuff undersurface into the
subacromial-subdeltoid bursa. The retracted tendon
margins may be thickened in response to healing or
attenuated in more chronic tears. The uninvolved areas
of tendon adjacent to the tear site may demonstrate
changes of degeneration or partial-thickness tear. The
quality of the retracted tendon edges can be assessed on
conventional MRI by assessing their appearance and
describing them according to the classification scheme
discussed earlier (good, fair or poor),187 and at MR
arthrography by evaluating for the presence of contrast
imbibition.23,32,57,230
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C H A P T E R 99 ■ S HOULDER 3235

A B
F I G U R E 99-36

Moderate complete tear. A, Coronal oblique and B, sagittal oblique fast spin-echo T2-weighted images with fat
saturation. There is a complete tear of the supraspinatus tendon, retracted to the mid humeral head, involving the
central to anterior aspect. There is degeneration of the medial tendon edges (arrows).

A B
F I G U R E 99-37

Massive tear. A, Coronal oblique T2-weighted image. The supraspinatus tendon is retracted to the medial glenoid
margin (arrow). There is severe atrophy. B, Sagittal oblique T2-weighted image. Note the “bald humeral head.” The
tear extends from the subscapularis to the infraspinatus tendon (arrows).

Secondary signs188,229 of rotator cuff tears are utilized
less commonly, with increased experience, and with
better depiction of the primary tendon defects. These
secondary signs include diffuse loss of the peribursal fat
plane and the presence of fluid in the subdeltoid bursa.
Loss of the peribursal fat plane in association with a
rotator cuff tear is most likely related to the presence of
bursal fluid and/or inflammatory change, granulation or
scar tissue.112,231 A large amount of fluid in the subdeltoid
bursa is believed to represent extension of joint fluid
through the capsule and tendon defect into the bursa. It
has been considered a more specific finding of a
complete cuff tear, particularly if a large volume of liquid
signal is present.229 Nonetheless, smaller amounts of
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3236 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-38
Moderate size full-thickness tear. Coronal oblique T1-weighted MR
arthrogram with fat saturation. High signal contrast outlines a defect in the
supraspinatus tendon. The tendon edges are mildly frayed (arrow).
fluid in the subdeltoid bursa can be identified quite
commonly in patients without a tendon defect, espe-
cially on fat-suppressed images, and may be indicative of
bursal inflammation (see Figs. 99-20, 99-27, and 99-28).
Fluid in the subdeltoid bursa may also be seen in patients
with partial tears, especially those on the bursal surface.
Although less common, large amounts of fluid in the
subdeltoid bursa may also be identified with primary
subdeltoid bursitis in patients with calcium hydroxy-
apatite deposition disease (HADD) (see later) and other
inflammatory causes.96
Muscle atrophy is a secondary sign seen especially in
association with large tears and chronic tears (Figs.
99-37, 99-39, and 99-40).187,232-237 It is best identified on
A B
F I G U R E 99-39
Posterior extension of large full-thickness tear. A and B, Coronal oblique fast spin-echo inversion-recovery–weighted
images. The tendon defect is retracted to the medial one third of the humeral head (arrow in A). In B the posterior
extension of the tear into the infraspinatus tendon is seen (arrow). The retracted tendon edges are globular and
degenerated.
T1- and proton-density–weighted images, particularly in
the sagittal oblique plane, and is not easily seen on fat-
suppressed imaging sequences. Atrophy may, however,
be seen in association with neurologic compromise,
adhesive capsulitis, and other conditions in which
shoulder movement is restricted or absent, and therefore
in and of itself is not diagnostic of tendon disruption.238-240
Other findings associated with large or chronic
rotator cuff tears include a decrease in the acromial-
humeral distance to less than 7 mm and the presence of
acromioclavicular joint cysts (Fig. 99-41). The former can
be seen on plain radiographs as well, but if associated
with a tear, MRI can be helpful to assess the extent of the
defect. Acromioclavicular joint cysts are associated with
full-thickness tears, usually large to massive, and occur
when a high riding humeral head impacts on the
overlying acromioclavicular joint. This leads to wear
on the inferior aspect of the acromioclavicular joint
capsule, with resultant tear. Fluid from the joint can then
extend through the tear and subdeltoid bursa, into the
acromioclavicular joint. Removal of the cyst alone must
be avoided because the condition tends to recur if
the cuff tear is not repaired. The rotator cuff should be
repaired and the cyst excised.241-243 Large joint effusions
may also accompany rotator cuff tears. This is a non-
specific finding. A recent study revealed the relationship
between intramuscular cysts of the rotator cuff and tears
of the rotator cuff244: intramuscular cysts of the rotator
cuff are associated with small, full-thickness tears or
partial undersurface tears of the rotator cuff (Fig. 99-42).
These cysts are best identified on imaging sequences
with T2-weighted contrast.
In more chronic tears a discrete tendon defect can
be more difficult to discern due to partial or complete
obliteration of the tear due to scarring. Severe mor-
phologic changes, a decrease in the acromial-humeral
distance, atrophy, and peribursal and bursal changes can
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C H A P T E R 99 ■ S HOULDER 3237

A
B

F I G U R E 99-40

Anterior and posterior extension of large full-thickness

tear. A, Coronal oblique T2-weighted image. The
supraspinatus tendon is retracted to the medial one third
of the humeral head (arrow). The tendon edges are thin.
There is moderate muscle atrophy. B, Coronal oblique
T2-weighted image, more posteriorly. The defect
extends posteriorly to the infraspinatus tendon in a fluid
filled longitudinal cleavage plane (arrow). C, Axial T2-
weighted image. The tendon lesion extends anteriorly
across the rotator interval to involve the superodistal
subscapularis tendon (arrow).

help in the recognition of these lesions on conventional

MR images.96 MR arthrography may be helpful in such
cases if doubt remains about the presence and extent of
such tears and surgery is contemplated.
MRI can also accurately determine the size of the
tendon defects,187,188,245-247 including the amount of
medial retraction, the anteroposterior extent of the
defect, as well as the overall cross-sectional area. As
noted earlier the cross-sectional area of the tendon
defect may be the most important factor in surgical
planning. Sagittal and coronal oblique sequences can
assess the medial and anteroposterior extent of cuff
tears. In conjunction with axial views they can also
determine the number of tendons involved, including
supraspinatus, infraspinatus, and subscapularis tendons,
as well as the location of the tendon defect (see Figs.
99-39 and 99-40).
The site of rotator cuff tears can also be determined
with MRI.82,177,179,187,188,234,248,249 Small full-thickness tears
F I G U R E 99-41
are often found in the anterior portion of the distal
supraspinatus tendon, near its insertion into the Acromioclavicular joint cyst. Coronal oblique fast spin-echo T2-weighted
greater tuberosity at the junction with the biceps and image. A large acromioclavicular joint cyst is seen (long arrow), associated
subscapularis tendon (near the rotator interval). They with a retracted full-thickness rotator cuff tear (short arrow).
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3238 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-42

Intramuscular cyst. A and B, Coronal oblique STIR images. Note the full-thickness tear in A (arrow) and the
associated intramuscular cyst in B (arrow).

A B
F I G U R E 99-43

Small complete tear. A, Coronal oblique and B, sagittal oblique fast spin-echo T2-weighted images with fat
saturation. Note the small rotator cuff tear outlined by fluid signal (arrows). Small tears tend to begin and occur at the
anterior distal supraspinatus tendon near its insertion.

are therefore best seen on far anterior coronal oblique
images or on lateral sagittal oblique images (Fig. 99-43).
Partial-thickness tears show a predilection for this area
as well. When larger, the tears extend to involve the
infraspinatus tendon from anterior to posterior aspect
(see Figs. 99-37, 99-39, and 99-40). The component of the
tear involving the infraspinatus is seen on the more
posterior coronal oblique images or on sagittal oblique
images. Anterior tears and larger tears may extend to
involve the rotator interval capsule and the subscapularis
tendon and there may be an associated lesion of the
biceps tendon (Figs. 99-40 and 99-44). The biceps tendon
is often implicated in these situations since it lies
beneath the anterior aspect of the supraspinatus tendon,
which then subjects it to even further impingement
between the humeral head and acromion when the
supraspinatus tendon is torn. Subscapularis and infra-
spinatus tears may also be visualized in the sagittal
oblique and axial plane images in addition to the coronal
oblique plane where the supraspinatus tendon defects
are best seen. In larger tears and anterior tears of the
supraspinatus tendon, axial images superior to the
glenohumeral joint may also demonstrate the fluid-filled
tendinous gap.
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C H A P T E R 99 ■ S HOULDER 3239

A B
F I G U R E 99-44

Rotator interval anterior tear. Biceps lesion. A, Coronal oblique fast spin-echo T2-weighted image with fat saturation.
Note the tear in the anterior supraspinatus tendon. The torn tendon fibers are markedly thickened and show
degeneration of the edges (arrow). B, Axial fast spin-echo T2-weighted image with fat saturation. The tear extends
anteriorly, likely disrupting the rotator interval, and the superodistal aspect of the subscapularis tendon, leading to
instability of the proximal aspect of the long head of the biceps tendon which migrates medially (“hidden lesion”)
(arrow).

A B
F I G U R E 99-45

Muscle atrophy. A, Coronal oblique proton-density–weighted image. Note the retracted supraspinatus (black arrow).
The supraspinatus muscle reveals muscle atrophy manifested by a decrease in bulk and infiltration by fat (white arrow).
B, Sagittal oblique T1-weighted image. Note the presence of atrophy in both the supraspinatus and infraspinatus
muscle bellies (arrows).

The presence of muscle atrophy187,232,234-237,250,251 is, as
noted earlier, a secondary sign associated with a rotator
cuff tear, and the degree and presence of muscle atrophy
is highly correlative with the size of the tear. Muscle
atrophy has importance in determining surgical out-
come with regard to return of muscle strength. Atrophy
is identified as a decrease in muscle bulk and size. There
will be an increase in fat signal within the muscle belly,
often appearing as linear bands of high signal on T1-
and proton-density–weighted images, though other
patterns may be seen (Fig. 99-45). This may be separately
described as fatty infiltration (degeneration).190,235,251
Images with fat suppression only are less helpful in
evaluating muscle atrophy except for visualization of a
decrease in muscle bulk. The degree of muscle atrophy
and fatty infiltration is most commonly graded as mild,
099.qxd 17/6/05 12:56 PM Page 3240
3240 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
moderate, and severe. Thomazeau et al237 developed a
ratio using an image in the oblique sagittal plane which
crosses the scapula through the medial border of the
coracoid process. They stated that this view allowed a
reliable measurement of supraspinatus muscle atrophy
by the calculation of an occupation ratio (R), which was
the ratio between the surface area of the cross-section of
the muscle belly and that of the supraspinous fossa.
Zanetti et al236 described the use of standardized cross-
sectional areas for quantitative assessment of the muscle
bulk of the rotator cuff with MRI. Standardized cross-
sectional areas were determined by the rotator cuff
muscle area divided by the area of the supraspinatus
fossa. They also described a tangent sign which is based
on their assumption that a healthy supraspinatus muscle
crosses a line (tangent) drawn through the superior
borders of the scapular spine and the superior margin
of the coracoid. Sagittal T1-weighted turbo spin-echo
images of the shoulder were utilized. Goutallier
et al189,190 graded the degree of muscle atrophy and fatty
infiltration into five grades of fatty degeneration of the
rotator cuff muscles.
Assessment of the status of the torn tendon edges is
also important for the operating surgeon in preoperative
evaluation. MRI and MR arthrography can be used to
assess the appearance of the torn tendon edges and
to indicate whether they are of good quality, or are
frayed or fragmented and of poor quality (see Figs. 99-38,
99-39, 99-40, and 99-44), or imbibe contrast and are
degenerated as determined by MR arthrography (see
Fig. 99-38).57,187,188,247
Diagnostic Performance
The diagnostic performance of MRI in rotator cuff
disease has been studied.8,96,187,188,217,218,220,227,228 Most
studies have found a high sensitivity, specificity, and
accuracy in the region of 90% to 95%. For partial-
thickness tears the sensitivity is decreased and more
variable but the majority of studies have determined a
diagnostic performance in the region of 85%. Improved
diagnostic performance is seen with fat-suppression
techniques.
Other investigators have tested the diagnostic per-
formance of fast spin-echo techniques in the evaluation
of rotator cuff tears and have found them to be similarly
efficacious. Performance is better with fat suppression,
especially in the diagnosis of partial tears.2,3,6,252
Recently the assessment of the rotator cuff with low
field extremity magnets has come into increased usage.
Results using these techniques with experienced
musculoskeletal radiologists approach those with higher
field systems.210,221
MR arthrography can improve the diagnostic
performance and confidence in the evaluation of rotator
cuff tears19,26,32,35,39,57,180,253 over conventional T2-
weighted MRI, particularly in the evaluation of partial-
thickness tears of the undersurface. It is not useful in the
assessment of partial-thickness tears confined to the
bursal side of the cuff or intrasubstance tears unless
post-contrast images with T2 weighting are employed.
The use of the ABER position may improve the
diagnostic performance of MR arthrography in certain
clinical circumstances as well.39 The sensitivity and
specificity of MR arthrography in the evaluation of
complete tears approaches 100%.29 The diagnostic
performance of MR arthrography is improved with the
use of fat suppression.32,34 Fat suppression helps in
confirming that the high signal above the tendon in
the subacromial-subdeltoid bursa region is contrast and
not fat in the peribursal fat plane. Fat suppression also
improves the diagnostic accuracy of detecting small
partial tears of the undersurface.32,34 The diagnostic
performance of indirect MR arthrography 45,47,254 reveals
comparable sensitivities and specificities for rotator
cuff pathology.
Tears of the Subscapularis Tendon
Involvement of the subscapularis tendon is relatively
uncommon but is being recognized more frequently
with better understanding of the causes of injury and
improved imaging techniques. Tears of the subscapularis
are recognized in 8% of patients in association with tears
of other components of the rotator cuff.167
Injury to the subscapularis may also occur with larger
tears of the rotator cuff as well as anterior tears (see Figs.
99-40 and 99-44). Incomplete tears of the subscapularis
tendon may also occur in conjunction with small or
medium-sized tears of the supraspinatus tendon. In a
study of 46 cadaver shoulders,255 20 shoulders had a tear
of the supraspinatus tendon and 17 had a tear of the
subscapularis tendon. The majority were articular-side
incomplete tears on the upper portion. Lesions of the
long head of the biceps brachii were identified in 14
(30.4%) shoulders. On MRI these articular-side partial
tears were identified as an area of high signal intensity on
axial T2-weighted images.
Degeneration and tearing of the subscapularis (as
well as the rotator interval capsule) may also occur in
patients with subcoracoid impingement.256-260 Sub-
coracoid impingement leads to subscapularis tendon
impingement pathology, visible on MR examination,
similar to that described with the stages of supraspinatus
impingement (see Fig. 99-46). Thickening and fluid may
also be present in the subcoracoid bursa.259 Fluid in the
subcoracoid space, revealed on MRI of the shoulder, may
lie in the subcoracoid bursa or the subscapularis recess.
Subcoracoid effusions may also be associated with
anterior rotator cuff tears, including tears of the rotator
interval.261
Isolated injury of the subscapularis is uncommon.
Acute isolated ruptures of the subscapularis can occur
with severe trauma. Traumatic injury of the subscapu-
laris is caused either by forceful hyperextension or
external rotation of the adducted arm. Such injury may
also occur in elderly patients with recurrent anterior
dislocation.163,164,167,168,178,262,263
On MRI examination the spectrum of pathology in
the subscapularis may range from advanced thickening
and increased signal on images with T1- and proton-
density–weighted contrast, reflective of tendinosis, to
partial-thickness tears in the substance and in the
superior distal insertion (Fig. 99-46). Full-thickness
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C H A P T E R 99 ■ S HOULDER 3241

CP

A B
F I G U R E 99-46

Subscapularis lesions. A, Axial fast spin-echo T2-weighted image with fat saturation. The subscapularis tendon is
thickened and there is increased signal in its substance, findings which are reflective of tendinosis (arrow). B, Axial fast
spin-echo T2-weighted image with fat saturation. In addition to thickening and increased signal, note the focus of
linear fluid signal in the substance of the subscapularis tendon, reflective of an intrasubstance partial tear (white arrow).
Note the cyst in the lesser tuberosity (black arrow) and the narrow subcoracoid space, reflective of subcoracoid
impingement. CP, coronoid process.

tendon tears are associated with fluid signal on images

with T2-weighted contrast and with medial tendon
retraction (Fig. 99-47). Less commonly, fluid may extend
into the subdeltoid bursa. Use of both the sagittal
and axial images aid in the assessment of tears of the
subscapularis tendon.75,167,179,181
Subscapularis tendon rupture may be associated with
disruption of the stabilizers of the biceps, such as the
transverse humeral ligament, as well as the coraco-
humeral ligament within the rotator interval. This may
then result in medial subluxation or dislocation of the
biceps tendon,264,265 and is best seen on axial images
(see Fig. 99-46).

Infraspinatus and Teres Minor injuries F I G U R E 99-47

Most tears of the infraspinatus tendon occur in
association with large tears of the supraspinatus tendon
or with injury to the teres minor tendon in posterior
dislocation.184,266 Isolated injury of the infraspinatus
tendon is not that common. It may occur in younger
patients who subject this area to stress in overhead
motion or as part of the posterosuperior subglenoid
impingement syndrome.143 Full-thickness tendon defects
may be seen in all three imaging planes and the criteria
are similar to those for tears of the supraspinatus tendon,
with the lesion appearing as a fluid-filled defect on
images with T2-weighted contrast (see Fig. 99-48).
Injuries of the teres minor without other rotator cuff
injury may be identified with MRI and MR arthrog-
raphy,184 but are not common. They may occur after
posterior dislocation in association with posterior
capsular tears. Injuries may range from muscle edema to
partial and complete tendon tears. Tendon tears are
manifested by tendon discontinuity on MRI exami-
Subscapularis tear. Biceps dislocation. Axial short tau inversion recovery
(STIR) image. Note the retracted torn subscapularis tendon (white arrow)
with medial dislocation of the long head of the biceps tendon (black arrow).
nation. The tendon may be avulsed from its insertion
into the greater tuberosity. MR arthrography may also
reveal extravasation of contrast material behind the
shoulder joint.184
Rotator Interval Lesions
Rotator interval tears are a clinically important subtype
of rotator cuff tear. Tears of this region may be difficult
to diagnose with MRI. Differentiation of a true rotator
interval tear from normal synovium and capsule in this
space may often not be possible with MRI and symptoms
may be referred and misleading.76,267
099.qxd 17/6/05 12:56 PM Page 3242
3242 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
A B
F I G U R E 99-48
Infraspinatus tear. A, Coronal and B, sagittal fast spin-echo T2-weighted images with fat saturation. Note the isolated
tear of the infraspinatus tendon (arrows).
The rotator interval is defined as the space between
the superior border of the subscapularis muscle and
tendon below and the supraspinatus muscle and ten-
don above77,78,268 (Fig. 99-11). It is a complex region
and can be conceptualized in layers.68,269 The outer-
most layer consists of fibrofatty tissue and beneath this
is the coracohumeral ligament, the joint capsule, and
then the superior glenohumeral ligament. The deepest
structure in the anterior interval is the long head of the
biceps tendon. Surgeons may enter the joint through this
region for an arthrotomy. It is through this interval that
the long head of the biceps tendon enters the shoulder
joint from the proximal bicipital groove to extend to
the superior labral-biceps anchor and the supraglenoid
tubercle attachment. The interval is bridged by the rotator
interval capsule.270 The fused rotator interval capsule
and the coracohumeral ligament may be seen as a roof
over the biceps tendon, and are important anterior
supporting structures for shoulder function.
It is believed that injury or deficiency of the rotator
interval capsule and coracohumeral ligament may lead to
posterior inferior laxity and instability.270 Lesions of the
rotator interval may also be seen in association with
shoulder subluxations and dislocations, where this region
may be an area of relative weakness susceptible to injury
and therefore during which time this region may be torn
or enlarged. As such many surgeons believe this area
should be repaired or reinforced during stabilization
procedures for instability.
Injuries to this interval may also occur in individuals
without a history of instability.268 In this circumstance
there may be an anterior tear of the supraspinatus
tendon as well as a tear of the superior subscapularis
tendon, in association with the tear of the interval.
Isolated lesions of the rotator interval appear thin and
longitudinal, and are not associated with muscle
retraction.267 Tears of the rotator interval may cause
communication with the subdeltoid bursa, and fluid or
contrast may be seen in this region on conventional MRI
and MR arthrography. This may be identified along with
altered signal in the region of the interval involving
structures such as the coracohumeral ligament and the
long head of the biceps tendon, without necessarily
involving the supraspinatus tendon. This may be
confusing if this anatomy and lesion are not understood.
Lesions of the rotator interval may often be best dis-
cerned on sagittal oblique T2-weighted imaging sequences
with fat suppression, or with MR arthrography.
The structures that contribute to the functional
anatomy of this region, or may be injured in association
with them, include the anterior margin of the
supraspinatus tendon, distal superior margin of the
subscapularis tendon, coracohumeral ligament, rotator
interval capsule, superior glenohumeral ligament, and
long head of the biceps tendon. Injuries to the superior
labrum and biceps labral anchor may also occur, as well
as the ligamentous reflection pulley for the long head of
the biceps tendon formed by these structures at the
lateral margin of the rotator interval, extending to the
lesser tuberosity and proximal bicipital groove. It also
includes the transverse humeral ligament.
The lesions may be acute as after a dislocation, or
chronic as in overuse injuries. If acute, the alterations
may be identified as areas of edema, fluid signal, and
synovitis, and have high signal on T2-weighted images, or
if chronic, show areas of thickening and scarring,
revealed as areas of low-to-intermediate signal in the
region of the interval, including the coracohumeral liga-
ment and capsule (Fig. 99-49). Other associated injuries
may occur to the biceps tendon, including inflamma-
tion and tear, or with disruption of the transverse
humeral ligament, or tear of the subscapularis tendon at
099.qxd 17/6/05 12:56 PM Page 3243
F I G U R E 99-49
Rotator interval injury. Coronal oblique T2-weighted fast spin-echo
sequences with fat saturation. Fluid signal due to edema and synovitis, as
well as areas of thickening and scarring, revealed as areas of low-to-
intermediate signal in the region of the rotator interval, are noted (arrows).
Fluid is also present in the anterior aspect of the subdeltoid bursa.
its attachment to the lesser tuberosity, biceps instability
including medial dislocation. With interval disruption
tearing of the distal anterior supraspinatus tendon at its
insertion into the greater tuberosity, “the anterior or
leading edge”at the lateral rotator interval may also occur.
Owing to the course of the long head of the biceps
through the interval to the superior labrum, SLAP lesions
may also occur.76
These lesions are often better recognized on sagittal
oblique sections or axial sections, acquired as either
T2-weighted fast spin-echo imaging with fat suppression
or with MR arthrography.When any one of the spectrum
of these associated injuries is suspected or found all
other possible associated injuries should be searched for
on MR examination.76
Rotator Cuff Tear Arthropathy
Rotator cuff tear arthropathy186,271,272 occurs in the
setting of large-to-massive tears (Fig. 99-50). In addition
to the presence of the advanced disruption of the cuff
there is abrasion of the humeral head articular cartilage
against the coracoacromial arch, causing subacromial
impingement that in time erodes the anterior portion of
the acromion and the acromioclavicular joint. There
may be collapse of the soft, atrophic humeral head,186
with eventual erosion of the glenoid and coracoid.
While many of these findings may be visible on plain
radiographs,185 MRI can help assess the full extent of
bone and soft-tissue involvement. This process should
be recognized and described at the time of MRI
evaluation, as the best treatment for this may be total
shoulder replacement, if possible with rotator-cuff
reconstruction.186
C H A P T E R 99 ■ S HOULDER 3243
F I G U R E 99-50
Rotator cuff arthropathy. Coronal oblique fast spin-echo T2-weighted
image with fat saturation. There is a large retracted full-thickness tear
(black arrow). Changes of rotator cuff arthropathy are seen. Note the
decrease in the acromiohumeral distance, the scalloping and resorption of
the undersurface of the anterior acromion (arrowhead), and the fraying and
thinning of the articular cartilage of the humeral head, along with cystic
change (white arrow).
Biceps Tendon
The biceps tendon may also become involved in patients
with impingement and rotator cuff tears.79,89,223,273-281 In
general the extent of disease in the biceps is less severe
than that in the cuff, but follows the progression seen in
the rotator cuff. A small amount of fluid may be observed
in the biceps tendon sheath even in asymptomatic
individuals.111 Since the tendon sheath communicates
with the joint it may fill with fluid when a shoulder joint
effusion is present from some other cause; therefore, this
is a nonspecific finding. Tenosynovitis can be diagnosed
when the amount of fluid in the tendon sheath is out of
proportion to that in the joint.
Tendinosis of the biceps tendon may manifest by an
increase in tendon size and increased signal in its
substance on T1- and proton-density–weighted images
(Fig. 99-51). With T2-weighted fast spin-echo imaging
with fat suppression or fast spin-echo STIR the increased
signal may persist or mildly increase.
In shoulders with tears of the rotator cuff the biceps
also becomes an active depressor of the head of the
humerus.282 On MRI examination the biceps may enlarge
as a response to this increased workload. This is
sometimes termed “tendonization.”
Partial-thickness tears may be more easily discerned
when there is alteration in morphology, such as thinning,
irregularity, or splitting of the tendon. Biceps tendon
ruptures may be seen with anterior tears of the rotator
cuff (Fig. 99-52). Up to 7% of large rotator cuff tears are
also accompanied by biceps tendon rupture. After a tear,
the intracapsular portion of the tendon lies free in the
joint cavity while the extra-articular portion is pulled
distally. With MRI the tendon is absent from the groove
which is filled with fluid. Distal retraction of the muscle
099.qxd 17/6/05 12:56 PM Page 3244
3244 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-51
Biceps tendinosis. Sagittal oblique T2-weighted image with fat saturation.
Note the high-grade partial tear in the supraspinatus tendon (long arrow).
The biceps tendon is thickened and shows increased signal in its substance
reflective of tendinosis (short arrows).
and tendon may be seen, best identified in longitudinal
planes of section. Occasionally the intertubercular
groove may fill with scar tissue of low signal and may
lead to a false-negative diagnosis.
Medial dislocation of the biceps tendon may also
result from chronic impingement, associated with a large
anterior cuff tear.13,179,273,277-279 There is tearing of the
secondary biceps stabilizers, including the anterior
supraspinatus and subscapularis tendons, and the
coracohumeral ligament. The low signal tendon is
displaced medially outside the intertubercular groove
(see Figs. 99-44 and 99-47). This is best seen on axial
A B
F I G U R E 99-52
Biceps tendon rupture. A, Coronal oblique and B, axial T2-weighted images with fat saturation reveal the torn
rotator cuff involving the supraspinatus tendon in A and subscapularis tendon in B (arrows). The biceps tendon is rup-
tured and retracted to the region just below the humeral neck (arrowheads). Note the empty, fluid-filled groove in B.
views. There may be an extra-articular tendon disloca-
tion with an intact subscapularis. With rupture of the
subscapularis tendon either post trauma or with a large
or massive cuff tear the biceps tendon may also dislocate
intra-articularly. The biceps tendon may then extend into
and be entrapped in the joint.
Calcium Hydroxyapatite Deposition Disease
The shoulder is the most common site of involvement
with calcium hydroxyapatite crystal deposition disease
(HADD). Patients may often be asymptomatic, but
clinical symptoms occur in 30% to 45% of patients in
whom calcifications are present. The disorder occurs in
both males and females, usually between the ages of 40
and 70 years. The pathogenesis of hydroxyapatite crystal
deposition is unknown, though trauma, ischemia, or
other systemic factors may induce abnormalities in the
connective tissue, leading to crystal deposition.283-285
Crystal deposition most commonly occurs in the
tendinous and bursal structures about the shoulder,
particularly the supraspinatus tendon (see Fig. 99-53)
(52%). It may become bilateral in up to 50% of
patients.283 In the supraspinatus tendon it may target the
critical zone, as this may be an area of both altered
vascularity and mechanical pressure, which therefore
may predispose it to hydroxyapatite crystal deposition.
It may also occur in the other tendons of the rotator
cuff, or in the biceps tendon. Bursal calcification is most
common in the subacromial-subdeltoid bursa. These
crystals incite a synovitis, tendinitis or bursitis and
periarticular inflammation. The calcification alone may
not be the inciting agent, but symptoms may occur with
the dissolution of the calcium.With rupture of a calcific
deposit, hydroxyapatite crystals are spilled into the
surrounding soft-tissue space or bursa, setting off an
099.qxd 17/6/05 12:56 PM Page 3245
acute inflammatory response. Milwaukee shoulder con-
sists of a destructive arthropathy, hydroxyapatite deposits,
high collagenase activity in the synovial fluid, and rotator
cuff tears.271,286
The nodular calcific deposits in HADD can usually be
easily seen with plain radiographs and the combination
of radiographs and the characteristic history is usually
sufficient for diagnosis and subsequent therapy. When
MRI is obtained in these patients the calcific densities,
usually of low signal intensity, may be difficult to see,
especially when small, due to the lack of contrast with
the low signal of the tendons (Fig. 99-53). They are
difficult to differentiate from a thickened tendon
without calcification.287 It may be difficult to distinguish
a calcified tendon from a thickened tendon without
calcification. They may be more easily identified when
they are large, or if there is subjacent high signal on
images with T2-type contrast, related to peritendinous
edema and inflammation. T2*–gradient-echo images may
also enhance visualization by providing a blooming
effect. Although areas of high signal intensity may be
observed about foci of calcification in tendons and
bursae on T2-weighted spin-echo MR images and after
injection of gadolinium intravenously, the correlation of
such findings to calcific tendinitis and bursitis has not
been proved.191,288
When the calcifications are seen, MRI can localize the
specific tendons or bursa involved and document
associated changes such as tendinitis, or the less common
tears. Tears of the rotator cuff can occur in association
with calcific tendonitis, though the mechanism is not yet
clear.289 It may relate to localized hyperemia in the
tendon, which may lead to impingement.
A B
F I G U R E 99-53
Calcium hydroxyapatite crystal deposition disease (HADD). A, Coronal and B, sagittal oblique fast spin-echo
T2-weighted images with fat saturation. There is a nodular focus of low signal consistent with calcium in the central
aspect of the supraspinatus tendon (arrows). Fluid is also seen in the subdeltoid bursa (arrowhead).
C H A P T E R 99 ■ S HOULDER 3245
The presence of effusions in the subacromial-sub-
deltoid bursa can be identified, particularly after
extrusion of the calcifications into the bursa. MRI may
also be helpful in these patients to exclude other causes
of shoulder pain. In patients with Milwaukee shoulder
the extent of joint destruction may be determined and
the presence of a rotator cuff tear, as well as its extent,
can be documented.
Bone Injuries
Nondisplaced fractures and bone contusions about the
humeral head (Fig. 99-54) and greater tuberosity may
result in pain and associated contusion-like injuries of
the rotator cuff that may mimic pain due to rotator cuff
tears. Anzilloti et al213 found that this tended to occur
in younger patients and in atypical locations of the
supraspinatus tendon. This post-traumatic strain of the
rotator cuff was typically associated with a bone bruise
in this study.213
SHOULDER INSTABILITY
General Features
The shoulder is considered the most unstable joint in the
human body. A simple definition of instability indicates
that the humeral head slips out of its socket during
activities. In the past it was considered to be present only
if a previous dislocation had occurred. Now more subtle
degrees of instability are well recognized, including
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3246 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-54
Greater tuberosity contusion. Coronal inversion-recovery–weighted
image reveals a greater tuberosity contusion (long arrow). Also note there
is mildly increased signal in the supraspinatus tendon which could reflect
post-traumatic strain or contusion (short arrow). The small amount of fluid
in the subdeltoid bursa may indicate some post-traumatic bursitis
(arrowhead).
subluxation and instability that results from micro-
trauma.70,290 Although the humeral head may translate a
small amount during daily activities, these more subtle
types of instability may result in pain from spasm or
capsular stretching. The traditional forms of instability
should be differentiated from glenohumeral joint laxity,
in which asymptomatic passive translation of the humeral
head on the glenoid fossa is observed. Glenohumeral
joint laxity and instability may however coexist.
Instability may be classified according to frequency
(acute, recurrent, or chronic), degree (subluxation or
dislocation), etiology, and direction.291,292 With regard
to etiology, instability may result from one specific
traumatic episode (termed traumatic instability), from
repetitive microtrauma in activities such as swimming or
throwing, or without any history of trauma (termed
atraumatic instability). In the latter cases there is often
a coexistent history of congenital ligamentous laxity.
Shoulder instability can also be described by direction
as anterior, posterior, or inferior to the glenoid, or
multidirectional.291,292 Anterior instability is by far the
most common type of instability. Functional instability is
another term used to describe instability and it indicates
that derangement of the shoulder is caused by damage
that may be confined to the glenoid labrum.293,294 The
shoulder may catch, slip, or lock and may not exhibit
subluxation or dislocation. Another term in current use
to define different types of minor instability is micro-
instability. This is said to occur in some 5% of patients. It
is a spectrum of disorders involving the upper half of the
shoulder joint, as opposed to more traditional instability
which involves the lower third to half. Involved in the
etiology of this process are entities such as a lax rotator
interval and there may also be a history of overuse in
these patients.295,296
Anterior Instability
Clinical Features
Recurrent subluxation or dislocation (shoulder insta-
bility) is the most frequent complication of acute
traumatic dislocation. When the initial event occurs
between the ages of 15 and 35 years the dislocations
usually become recurrent or habitual. Once a second
dislocation has occurred the patient becomes a “recur-
rent dislocator.” The recurrence rate in the younger age
group of patients is very high and may be as high as 80%
to 90%.297,298 Recurrences usually occur in the first
2 years. The damage to the shoulder seems to occur at
the time of the original trauma, though each redisloca-
tion may cause further damage. The incidence of
recurrence seems to be inversely related to the severity
of the initial trauma.293,299-301 There does not appear to
be a relationship between the length and type of immo-
bilization and the development of redislocation,293,294,302-304
though many surgeons still immobilize the shoulders of
younger patients for up 6 weeks in the hope of allowing
the damaged tissues to heal. Recurrences are more
common in men.
Over the age of 40 years the recurrence rate typically
drops to 15% or less.166 In older patients the spectrum of
lesions is different and there is more often a tear of the
rotator cuff or fracture of the greater tuberosity.
Pathologic Lesions
Patients with recurrent subluxations and dislocations
incur lesions to the capsular mechanism. The essential
lesion of instability described by Bankart is detachment
of the glenoid labrum and capsule from the anterior
glenoid margin.305 Others believe the most important
abnormality is a Hill Sachs defect.306-309 Fractures of the
inferior glenoid margin, insufficiency, stretching, or
avulsion of the subscapularis muscle and tendon, and
stretching rather than actual detachment of the anterior
capsule may also be important. Other factors include
aplasia or hypoplasia of the glenoid, variations in contour
of the glenoid fossa, excessive anteversion of the
glenoid, increased anteversion of the humeral head, and
muscle imbalances.54,310
True Bankart lesions are more commonly found in
patients with a history of complete traumatic disloca-
tion. In patient with a history of a subluxating shoulder
there may just be laxity or redundancy of the capsule,
though labral lesions, fractures of the glenoid rim, and
articular defects of the posterolateral humeral head may
also be seen. Damage to the glenoid rim and Hill-Sachs
lesions are more frequently found in complete traumatic
dislocation.310-314
Bone Abnormalities
The two most common bone abnormalities are Hill-
Sachs lesions and fractures of the inferior glenoid
margin. A Hill-Sachs lesion is a specific indicator of a
prior anterior glenohumeral joint dislocation. It is a
posterolateral notch defect in the humeral head that is
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C H A P T E R 99 ■ S HOULDER 3247

F I G U R E 99-55 F I G U R E 99-56

Hill-Sachs lesions. Axial T1-weighted image (TR/TE 800/17 ms) at the level Hill-Sachs lesion. Coronal oblique fast spin-echo T2-weighted image
of the coracoid process. A wedge-like defect is seen at the posterior (TR/TE 3916/54 ms) with fat suppression. A Hill-Sachs lesion with asso-
superior lateral aspect of the humeral head (arrows). ciated marrow edema is seen along the posterior superior aspect of the
humeral head (arrow).

created by impingement of the articular surface of

this portion of the humerus against the anteroinferior
rim of the glenoid fossa. It is most common in patients
with recurrent anterior subluxation and dislocation,315
and uncommon in patients with anterior subluxa-
tion alone,292 multidirectional instability, or labral pathol-
ogy not associated with recurrent subluxations or
dislocations.
On MRI, Hill-Sachs lesions appear as wedgelike
defects on the posterolateral aspect of the humeral head
(Fig. 99-55). They are identified above the level of the
coracoid process.315-318 They are best seen on axial
images, but may also be apparent on coronal and sagittal
oblique images (Fig. 99-56). Both the larger, more
traditional Hill-Sachs lesions and the minor impaction
injuries of the humeral articular cartilage and subchon-
dral plates that may be more easily appreciated with F I G U R E 99-57
arthroscopy can be seen. Hill-Sachs lesions should not be
Bony glenoid margin lesions (“bony Bankart”). Axial proton-density–
confused with the normal posterolateral flattening seen
weighted image. A large fracture fragment from the mid to anterior inferior
in the inferior aspect of the humeral head and which is glenoid is seen in this patient after anterior dislocation (arrows).
typically present below the level of the coracoid.318
Depending on their age, Hill-Sachs lesions may be asso-
ciated with marrow edema (see Fig. 99-56) or trabecular
sclerosis. MRI imaging was found to have a sensitivity of
97%, a specificity of 91%, and an accuracy of 94% in the involve at least one third of the glenoid surface in order
detection of a Hill-Sachs lesion.315 to necessitate bone grafting.319,323 When large, bony
The osseous Bankart lesion (Figs. 99-57 and 99-58) is a Bankart lesions may lead to reversal of the normal pear
defect in the anterior inferior margin of the glenoid shape of the glenoid surface, a situation that promotes
rim.319 Cross-sectional imaging with either CT or MRI recurrent dislocations. The bony glenoid rim lesions may
with or without intra-articular contrast injection can be be easier to interpret with CT, especially fractures and
helpful in depicting these lesions273,320-322 and determin- ectopic ossification, although lesions in the subchondral
ing their size and location. It is generally thought that a bone and marrow are more easily identified with MRI.
large defect should be treated with bone-grafting, but On MRI cystic change and sclerosis may be seen. STIR
there is a lack of consensus with regard to how large a images and/or intermediate or T2-weighted MRI images
defect must be in order to necessitate this procedure. with fat suppression in the sagittal oblique plane may
Some investigators have proposed that a defect must depict particularly well bone and marrow alterations
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3248 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
F I G U R E 99-58
Bony glenoid margin lesions (“bony Bankart”). Sagittal oblique T2-weighted
fast spin-echo image with fat suppression. A bone defect with marrow
edema of the anterior more inferior glenoid (large arrow) parallels the
labroligamentous avulsion. Note the anteriorly displaced, low signal bone
fragment (small arrow).
associated with Bankart lesions (Fig. 99-58). CT with
reformatted images with 3D reconstruction may aid in
determining the size of the defect and the need for bone
grafting to prevent recurrence after surgery.323-325
Labral, Capsular, and Ligamentous Lesions
General Features
The soft-tissue lesions associated with recurrent anterior
subluxation and dislocation include damage to the
anterior glenoid labrum, associated glenohumeral
ligaments (labroligamentous complex), and anterior
capsule.292,293,305,326-329 Specifically the “cartilaginous”
lesion as originally described by Bankart has been
considered to be an avulsion or tear of the glenoid
labrum and/or stripping of the joint capsule. The damage
to the anterior labrum that is seen at surgery, however,
may vary from detachment of the labrum from the
glenoid rim, to tears of the substance of the labrum, to a
completely destroyed or absent labrum.293
Injury to the labroligamentous complex typically will
involve the region of the anterior band of the inferior
glenohumeral ligament. Failure of this complex may
occur at its glenoid insertion site (70-75% of cases). The
labrum tears as it is avulsed by the glenohumeral
ligaments at the time of injury. Failure of this complex
may also occur at its humeral insertion site (5-10% of
cases), or in its substance (15-20%), whereby there will
be capsular failure due to tear or laxity. Those associated
with glenoid-sided failure include the Bankart lesion
described earlier and its less common variants, the
Perthes lesion and the anterior labroligamentous peri-
osteal sleeve avulsion (ALPSA) lesion. Lesions associated
with humeral failure include humeral avulsion of the
glenohumeral ligament (HAGL) and its bone counterpart
(BHAGL) lesion. Failure of this ligament at both its
glenoid and humeral insertion destabilizes both ends of
the anterior band of the inferior glenohumeral ligament
[floating avulsion of the inferior glenohumeral liga-
ment (AIGHL)].
A typical Bankart lesion would be an avulsion of the
labroligamentous complex from the anteroinferior
portion of the glenoid.329-331 The periosteum of the
scapula is lifted and disrupted. It occurs at the 3 to
6 o’clock position, but may extend upward. The soft-
tissue lesion may be avulsed together with a piece of
bone, the “bony” Bankart lesion, along the anteroinferior
aspect of the glenoid rim.307
Labral Lesions
The labrum has been divided into six quadrants:
I, superior; II, anterior superior; III, anterior inferior;
IV, inferior;V, posterior inferior; and VI, posterior superior.
Lesions of the glenoid labrum are considered to be a
reliable sign of instability. Normal variation occurs in the
superior and anterior superior portion from the 11 to
3 o’clock position, including the sublabral foramen and
the Buford complex. Pathology in the labrum associated
with anterior instability typically occurs in the anterior
inferior portion from the 3 to 6 o’clock position. Inter-
mediate signal occurs in the sublabral zone between the
articular cartilage of the glenoid.105 Another cause of
difficulty is the occurrence of magic angle phenomenon
in the labrum on short TE sequences.
The criteria used to diagnose an abnormality of
the glenoid labrum include alterations in its mor-
phology and/or signal intensity. Increased signal within
the labrum not extending to the surface reflects
internal labral degeneration.187 A torn labrum has mod-
erate or intense signal on short TR/TE, density-weighted
or gradient-echo images, extending to the surface of
the labrum, and brightens on T2-weighted or fat-
suppressed proton-density images (Fig. 99-59A) or
imbibes contrast into the defect at MR arthrography
(Fig. 99-59B).105,187,273,332-334 Abnormal labra may also
be blunted, eroded, or frayed and irregular.
The diagnostic performance of MRI and MR
arthrography in the evaluation of labral tears has been
evaluated. One study of conventional MRI found a
sensitivity of 93% and a specificity 87%.187 A larger study
found a sensitivity of 89% and a specificity of 97%.5
MRI was found to be most sensitive in the evalua-
tion of anterior labral tears and least sensitive in
superior and posterior tears. MRI arthrography reveals
a diagnostic performance similar to or better than con-
ventional MRI and better reveals labral separation/
detachment.33,56,273,335-338
Capsular Lesions
In patients with shoulder instability after one or
repeated dislocations and or subluxations there may
be traumatic avulsion of the capsule from its glenoid
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C H A P T E R 99 ■ S HOULDER 3249

A B
F I G U R E 99-59

Labral lesion. A, Anterior labral separation outlined by fluid signal on an axial fast spin-echo T2-weighted image with
fat suppression (arrow). The anterior labrum is also blunted and attenuated. B, Axial T1-weighted MR arthrogram
(TR/TE 800/20 ms) in another patient. Contrast outlines and imbibes into a complex tear in the anterior labrum (long
arrow). Note the attenuated glenohumeral ligament (middle) anterior to this (short arrow).

insertion. In the latter circumstance the capsule would Perthes Lesion

be peeled back to the neck of the scapula with the first
and subsequent dislocation. This is described as capsular
stripping or shearing.
The anterior inferior capsule and associated
glenohumeral ligaments (especially the anterior band of
the inferior glenohumeral ligament) can often best be
seen on arthrographic MR examination on fast spin-echo
proton-density, intermediate, or T2-weighted images with
fat suppression, or with T2*-weighted 2D gradient-echo
techniques, particularly when there is a significant
effusion. In the absence of an effusion MR arthrography
is very useful, especially to clearly identify the anterior
inferior labrum and inferior glenohumeral ligament.With
injury to this region fluid or contrast may also be seen to
extend beneath the soft tissue mantle. In a typical
Bankart lesion the labrum will be torn or detached with
the capsular structures and fluid signal or contrast may
extend within or beneath the labrum as well (Figs. 99-60,
99-61, and 99-62). The assessment of the capsule should
be at the midglenoid or below, since on the more
superior images a distended subscapularis bursa or
medial capsular insertion may mimic capsular strip-
ping.339 Evaluation of capsular stripping may then better
reflect disruption of the anterior inferior labral
ligamentous complex.223,340
Bankart Lesion Variants
The earlier discussion focuses on the typical lesion of
anterior instability—the Bankart lesion, which is an
avulsion of the anterior inferior labrum, capsule, and
inferior glenohumeral ligament complex, with an
associated disruption of the scapular periosteum (see
Fig. 60-62). There are however a number of variants of
this typical lesion.
This lesion341 is a labral ligamentous avulsion in which
the scapular periosteum remains intact but is stripped
medially. The periosteum may then become redundant,
and recurrent instability may occur as the humeral head
moves forward into this region of acquired laxity
(pseudojoint). The labrum may then lay back down into
a relatively normal position on the glenoid and
resynovialize (heal back). It may then be very difficult to
diagnose as the detachment may not be easily iden-
tified on conventional MRI or even on MR arthrog-
raphy (Fig. 99-63) (or at arthroscopy), unless specialized
imaging positions such as ABER are employed (Fig.
99-63).29,39,341 With distension from MR arthrography
and when needed with ABER positioning, only subtle
displacement of the labral tissue may be seen (see
Fig. 99-63).
Anterior Labroligamentous
Periosteal Sleeve Avulsion
The ALPSA lesion342,343 is anterior labroligamentous
sleeve avulsion. In these cases the scapular periosteum
does not rupture, resulting in a medial displacement and
inferior rotation of the labroligamentous structures as
they are stripped down to the scapular neck. The ALPSA
lesion may then heal in this displaced position. This has
also been termed a medialized Bankart lesion. A small
cleft or separation can then be seen between the glenoid
margin and the labrum. With a chronic ALPSA lesion
fibrous tissue is deposited on the medially displaced
labral ligamentous complex and the entire lesion then
resynovializes along the articular surface. This may leave
a deformed and redundant labrum. This lesion may
require a different repair from the typical Bankart lesion
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3250 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
and therefore it is important to recognize it.343-345 In the
absence of an effusion the ALPSA lesion may be missed
on conventional MRI if the lesion does not extend to
the mid anterior labrum, as the fibrous medialized
resynovialized mass may not be well seen on MRI
imaging (Fig. 99-64) in a patient with a paucity of joint
fluid and magic angle artifact.29 MR arthrography,
including the ABER position, may be valuable in reveal-
ing these lesion (Fig. 99-64).
Humeral Avulsion of the Glenohumeral Ligament
The HAGL lesion refers to humeral avulsion of the
glenohumeral ligament.346-349 This lesion more typically
occurs in individuals older than 30 years.349 It may be
seen in conjunction with a tear of the rotator cuff or
fracture of the greater tuberosity of the humerus. It is not
uncommonly associated with a tear of the subscapularis
tendon. This lesion can be seen on conventional MRI as
well as with MR arthrography (Fig. 99-65).346,347 On MRI
examination the torn glenohumeral ligament may appear
thick, wavy and irregular, with increased signal
intensity.346 MR arthrography may also show contrast
material extravasating from the joint through the
capsular disruption at its humeral insertion. It may be
feasible to repair this lesion athroscopically via reattach-
F I G U R E 99-60
Bankart lesion. A, Axial fast spin-echo T2-weighted
image with fat suppression. There is evidence of
detachment of the anterior inferior labroligamentous
complex from the glenoid margin (arrows). B, Axial
cadaver section from a specimen subjected to simulated
dislocations in the laboratory. Tear and detachment of the
anterior labrum is seen with disruption of the capsule and
scapular periosteum (black arrows). C, Bankart lesion
showing the anterior labroligamentous tear and detach-
ment (black arrow) with disruption of the scapular peri-
osteum. (Reproduced with permission from Zlatkin MB.
MRI of the Shoulder, 2nd ed. Philadelphia, Lippincott,
Williams and Wilkins, 2003. Drawn by Salvador Beltran.)
ment to the humerus via sutures. Recently, the HAGL
lesion was also seen after successful Bankart repair.350
The bony humeral avulsion of the glenohumeral
ligaments (BHAGL)351,352 is a rare lesion that may occur
after anterior dislocation of the shoulder. The bone
fragment may appear similar to a bony glenoid avulsion.
CT or MRI can show that the bone is attached to the
glenohumeral ligaments and does not originate from the
glenoid but rather from the bone at the site of humeral
attachment of the inferior glenohumeral ligament.
Posterior Instability
Posterior instability of the shoulder is not as well
understood as anterior stability, in part because it is
uncommon but also because of the confusion in
terminology differentiating posterior subluxations and
dislocations.291,353-355
Isolated posterior instability is uncommon and
accounts for only 5% of instability. Acute posterior
dislocations of the glenohumeral joint are rare
(approximately 2% to 4% of all dislocations of the
shoulder).356,357 They may occur following trauma but
are commonly associated with electric shocks or
seizures. Recurrence is not common.
099.qxd 17/6/05 12:56 PM Page 3251
A
Recurrence is very common with atraumatic
posterior dislocations and in patients with a history of a
traumatic dislocation when large bony defects of the
humerus and glenoid occur. Recurrent posterior
subluxation rather than dislocation is however the more
common lesion. Overuse as in athletics is usually
involved. Abduction, flexion, and internal rotation are the
mechanisms involved (swimming, throwing, and
punching), reflective of repeated microtrauma. These
patients, who are often young athletes, may present with
pain rather than signs of instability. There may be some
association with posterior laxity.353-355,358-364
The posterior band of the inferior glenohumeral
ligament is a primary static stabilizer of the gleno-
humeral joint with respect to translation posteriorly of
the humeral head. Injury sufficient to cause posterior
instability, however, requires injury to the posterior
inferior labroligamentous complex as well as the
posterior capsule. Pathologic findings in patients with
prior posterior dislocations and resultant instability
may be the reverse of those for recurrent anterior
C H A P T E R 99 ■ S HOULDER 3251
B
F I G U R E 99-61
Bankart lesion. A, Axial T1-weighted MR arthrogram
with fat suppression. There is evidence of detachment of
the anterior inferior labroligamentous complex from the
glenoid margin (true “Bankart” lesion) (arrow). B and
C, Axial T1-weighted MR arthrograms with fat suppres-
sion. Similar findings of a labroligamentous tear and
detachment are seen (white and black arrows in B, large
arrow in C). Note the small defect in the posterior labrum
(small arrow in C) and subjacent fragment (arrowhead).
dislocations and include posterior labral and capsular
detachments and tears, as well as posterior capsular
laxity.365 An impaction type defect on the anteromedial
aspect of the humeral head is known as a reverse Hill-
Sachs lesion (notch sign or trough lesion). Fractures of
the posterior glenoid margin and of the lesser tuberosity
may also occur. The subscapularis tendon may be
stretched or detached, and tears of the teres minor
tendon may occur. Posterior labrocapsular periosteal
sleeve avulsion (POLPSA) has also been described.366,367
The MR and MR arthrographic findings associated
with patients with posterior instability mirror those
described for anterior instability except they involve the
posterior capsule and labrum.339,361,368 The reverse Hill-
Sachs lesion is well seen on MR images (Fig. 99-66).
MRI and MR arthrography may be used to identify the
presence and extent of a tear and detachment of
the posterior labroligamentous complex (Fig. 99-66).
Although the posterior capsule is injured, the capsular
abnormalities may be less prominent than in anterior
instability.339 MR-evident abnormalities that involve
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3252 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-62

Bankart lesion. A, Axial fast spin-echo T2-weighted image with fat suppression. Note the injury to the anterior
capsulolabroligamentous complex with disruption of the scapular periosteum (white arrows). The labral
separation/detachment is not as well depicted as when the joint is distended with MR arthrography (see Fig. 99-61)
Also note the acute Hill-Sachs lesion (black arrows). B, Sagittal fast spin-echo T2-weighted image (TR/TE 3000/72 ms)
with fat suppression. Sagittal oblique images help reveal the extent of the injury, from superior to inferior (arrows)
(see also Fig. 99-58).

A B
F I G U R E 99-63

Bankart lesion variants. Perthes lesion. A, Axial T1-weighted MR arthrogram. The anterior labroligamentous complex
has healed back in a near normal position. The MR arthrogram outlines subtle displacement of the labral tissue
(arrow). B, Axial oblique abduction and external rotation (ABER) T1-weighted MR arthrogram in another patient.
Again only subtle displacement of the labral tissue is seen (arrow).
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C H A P T E R 99 ■ S HOULDER 3253

B
A

F I G U R E 99-64

Bankart lesion variants. Chronic anterior labroliga-

mentous periosteal sleeve avulsion (ALPSA) lesion.
A, Axial fast spin-echo T2-weighted image with fat
suppression. The fibrous medialized resynovialized mass
of intermediate signal intensity (arrow) is difficult to
discern on conventional MR images. B, Axial T1-
weighted MR arthrogram. A cleft of contrast material
outlines the anteromedially displaced healed-over mass
of labroligamentous tissue (arrow). C, Axial oblique
T1-weighted image taken in the abduction and external
rotation (ABER) position reveals the cleft of contrast
(black arrow) and the thickened anteromedially displaced
mass of labroligamentous tissue (white arrow).

F I G U R E 99-65

Humeral avulsion of the glenohumeral ligament (HAGL).

Axial fast spin-echo T2-weighted image with fat sup-
pression. The humeral attachment of the glenohumeral
ligament is markedly abnormal in signal intensity and
morphology (arrow).
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3254 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-66

Posterior instability. A, Axial T2-weighted (TR/TE 3100/47 ms) fast spin-echo image with fat suppression. The
posterior glenoid labrum and capsule are torn along the posterior glenoid margin (short arrow). There is a bony defect
on the anteromedial aspect of the humeral head consistent with a “reverse Hill-Sachs deformity.” It is associated with
marrow edema (long arrow). B, Sagittal oblique T2-weighted fast spin-echo image with fat suppression, carried out
after intra-articular fluid injection. The superior inferior extent of the labral tear/detachment is seen best in this
projection, outlined by the fluid signal and joint distension (arrows).

the bony glenoid include fractures or defects, although
findings of marrow edema or sclerosis and cystic lesions
may also be identified. In patients with atraumatic
recurrent posterior subluxation, joint laxity with redun-
dancy of the posterior capsule may be the most promi-
nent finding and a posterior labral tear may not be
found.354 This may also be associated with inferior
redundancy353,369 in which case multidirectional insta-
bility may result. MR arthrography may be the only
means of imaging able to reveal this laxity.
Isolated Labral Tears
The labrum can tear in the absence of subluxation or
dislocation. The tears that have been described in this
circumstance include flap or bucket-handle tears and
these lesions may be present in the anterior superior
portion of the labrum. They may respond to arthroscopic
excision. Isolated glenoid labrum lesions may occur in
the throwing athlete as fraying or separation in the
superior quadrant of the labrum adjacent to the origin of
the long head of the biceps. These patients present
with a painful catching or snapping sensation during
throwing. This is related to overloading of the biceps
tendon and subsequent avulsion of the superior part of
the labrum during the follow through. These lesions in
the labrum may be associated with pathology in the
rotator cuff. Injuries seen in the rotator cuff are often
partial tears of the rotator cuff undersurface more pos-
teriorly. MR arthrography may reveal these lesions best,
as contrast will leak into the labral tears, imbibe into
areas of labral fraying, detect areas of labral separation
or detachment, and leak or imbibe into undersurface
rotator cuff injuries.
Posterosuperior subglenoid impingement (see earlier)
occurs during the late cocking phase of throwing with
abnormal contact between the posterosuperior portion
of the glenoid rim and the undersurface of the rotator
cuff, and is thought to occur at the extremes of abduc-
tion and external rotation. A triad of findings has been
described in association with this lesion (Figs. 99-34 and
99-67): injury to the rotator cuff undersurface at the
junction of the infraspinatus and supraspinatus tendons;
degenerative tearing of the posterosuperior glenoid
labrum; and subcortical cysts and chondral lesions in the
posterosuperior glenoid and humerus due to repetitive
impaction. There may in addition be an injury to the
inferior glenohumeral ligament because it limits
abduction in external rotation of the glenohumeral joint
and is therefore under tension in this position.
SLAP Lesions
Snyder et al370-372 introduced this term to define injuries
to the superior portion of the labrum and adjacent
biceps tendon. A superior quadrant labral tear with
anterior and posterior components of the tear is labeled
a SLAP lesion (superior labrum anterior posterior). The
lesion may be acute or chronic and when acute they may
result from a fall onto the outstretched arm with the
shoulder in abduction and forward flexion. It also may
occur in athletes repetitively overusing the arm,295,373-375
including baseball, tennis, or volleyball players. The injury
to the superior portion of the glenoid labrum may result
from sudden forced abduction of the arm, i.e., excessive
traction related to a sudden pull from the long head
of the biceps tendon. The lesion may typically begin
posteriorly and then extend anteriorly and terminate at
099.qxd 17/6/05 12:56 PM Page 3255
A B
or before the midglenoid notch. It includes the biceps
labral anchor.
SLAP tears were categorized into four basic types
by Snyder et al.372 Type 1 (10% of SLAP lesions) reveals
superior labral roughening and degeneration. The labrum
remains firmly attached to the glenoid. This lesion may
represent a degenerative tear of the labrum. Type 2 is the
most common lesion (40%) and is a detachment of this
roughened superior portion of the labrum and its
biceps tendon anchor. Burkhart et al295,374 described
three distinct categories of type 2 SLAP lesions: anterior,
posterior, and combined anteroposterior. Type 3 (30%) is
a bucket-handle tear of the superior portion of the
labrum. It does not involve the biceps labral anchor.
Type 4 (15%) has in addition to the bucket handle tear a
split tear of the biceps tendon.
Additional types of SLAP lesions have been
described.273,373,376,377 Type 5 is a Bankart lesion of the
anterior inferior labrum that then extends superiorly to
include separation of the biceps tendon anchor. Type 6
lesions are unstable radial or flap tears that also involve
separation of the biceps anchor. A type 7 lesion consists
C H A P T E R 99 ■ S HOULDER 3255
F I G U R E 99-67
A, Axial; B, coronal; and C, sagittal oblique T1-weighted
images after intravenous gadolinium injection for intra-
venous MR arthrography. The rotator cuff shows
tendinosis more posteriorly (arrowhead in B). There is
cystic change in the humeral head posterosuperiorly
(black arrow in A). The labrum imbibes contrast,
reflective of degenerative-type tearing (white arrows).
Findings are consistent with posterosuperior glenoid
impingement.
of anterior extension of the SLAP lesion to involve the
middle glenohumeral ligament. Type 8 lesions extend
posteroinferiorly with extensive detachment of the
posterior labrum. A type 9 lesion is a complete con-
centric avulsion of the labrum circumferentially around
the entire glenoid rim.375
MRI and MR arthography may be used in the detec-
tion of SLAP lesions (Figs. 99-68, 99-69, 99-70, and
99-71).273,376,378-383 In the study by Cartland et al384 on
MRI examination, type 1 lesions exhibited irregularity of
the labral contour with mildly increased signal intensity.
Type 2 lesions may have revealed a globular region of
increased signal interposed between the superior
labrum and glenoid margin. Type 3 showed typical linear
increased signal extending to the labral surface. Type 4
lesions showed high signal within the superior labrum
and extending into the proximal biceps tendon. SLAP
lesions may be difficult to detect on conventional MR
imaging. The more superior portions of the tear can be
difficult to visualize on axial images. External rotation,
as well as coronal oblique images, help define these
lesions.382 MR arthrography can be very helpful in
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3256 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

B
A

F I G U R E 99-68

Superior labrum anterior posterior (SLAP) lesion.

A, Axial, and B and C, coronal oblique fast spin-echo
images (B, anterior; C, more posterior) with fat suppres-
sion. A continuous tear and detachment is identified in
the superior labrum, anterior and posterior (SLAP type 2)
(white arrows in A-C).

F I G U R E 99-69

Superior labrum anterior posterior (SLAP) lesion. Type 3

lesion. Coronal oblique T1-weighted MR arthrogram.
Contrast extension reveals detachment and mild
displacement of the superior labrum from the glenoid rim
(arrow). The biceps tendon insertion remains intact
(arrowhead). (Courtesy of Javier Beltran MD, New York.)
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C H A P T E R 99 ■ S HOULDER 3257

A B
F I G U R E 99-70

Superior labrum anterior posterior (SLAP) lesion. Type 4 lesion. A, Axial and B, coronal oblique fast spin-echo
images with fat suppression. A tear is identified in the superior labrum, anterior and posterior (long arrows) extending
into the proximal biceps tendon (short arrow in B).

A B
F I G U R E 99-71

Superior labrum anterior posterior (SLAP) lesion. Type 8 lesion. A, Axial fast spin-echo T2-weighted image (TR/TE
3000/55) with fat suppression. B, 2D gradient-echo image (TR/TE 400/22 ms, flip angle 25 degrees). There is a tear
of the superior labrum which extends posteroinferiorly (arrows).

detecting SLAP lesions, including the use of traction in
some select situations.385 It will distend out buckle-
handle type tears, outline morphologic alterations, and
imbibe into areas of degeneration and fraying of the
labrum and biceps tendon. MR arthrography demon-
strates the following signs in SLAP lesions386: 1. contrast
material may extend superiorly into the glenoid attach-
ment of the long head of the biceps tendon (LHBT) on
oblique coronal images; 2. irregularity of the insertion of
the LHBT on oblique coronal and sagittal images;
3. accumulation of contrast material between the labrum
and glenoid fossa on axial images; 4. detachment and
displacement of the superior labrum on oblique sagittal
and coronal images; and 5. a fragment of the labrum
displayed inferiorly between the glenoid fossa and the
humeral head. In addition, as noted later, a paralabral cyst
099.qxd 17/6/05 12:56 PM Page 3258
3258 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
A B
may be frequently associated with these lesions. In one
study MR arthrography had a sensitivity of 89%, a
specificity of 91%, and an accuracy of 90%.376
Tears of the superior portion of the labrum must be
distinguished from the normal variants of the labrum and
its attachments in this region. Among the criteria for
distinguishing these lesions from SLAP tears are that
these lesions do not extend to involve the superior or
posterior labrum beyond the level of the biceps labral
anchor and there should be no associated morphologic
alterations. In addition they should not extend below the
level of the equator of the glenoid which may be marked
by the coracoid process. Increased distance between the
labrum and the glenoid, an irregular appearance of the
labral margin, or lateral extension of the separation may
suggest a SLAP lesion rather than a normal anatomic
variant.380 As with other tears of the superior labrum,
SLAP lesions are frequently associated with rotator cuff
lesions, particularly partial tears. One study found such
lesions in 42% of cases.376
F I G U R E 99-72
Paralabral cyst. A, Axial; and B and C, (both posterior)
coronal oblique fast spin-echo T2-weighted sequences
with fat suppression. A large paralabral cyst is identified
(long arrows) arising in relation to a posterosuperior
labral tear (short arrows) and extending into the
spinoglenoid notch region.
Paralabral Ganglion Cysts
These are ganglion cysts arising adjacent to the glenoid
labrum387-389 and most commonly associated with a
labral tear (see Figs. 99-72 and 99-73). This labral tear is
often a SLAP lesion and the paralabral cyst most
commonly arises in relation to the posterosuperior com-
ponent (Fig. 99-72). It may, however, occur anywhere in
the glenohumeral joint. Pathophysiologically they may
be similar to cysts of this nature elsewhere in the body,
such as meniscal cysts or cysts associated with tears of
the acetabular labrum. In this situation fluid arising from
the joint extends through the labral tear into the
surrounding soft tissues and leads to ganglion cyst
formation. Paralabral cysts may be difficult to identify
on MR arthrography unless some form of T2-weighted
sequence is performed as direct communication between
a cyst and the joint space rarely occurs (see Fig. 99-46).
A posterior or inferior cyst may cause compression
neuropathy of the suprascapular or axillary nerve,
respectively. Compression of the suprascapular nerve is
099.qxd 17/6/05 12:56 PM Page 3259
A B
F I G U R E 99-73
Paralabral cyst. Infraspinatus atrophy. A, Axial fast spin-echo T2-weighted sequence and B, coronal oblique fast
spin-echo T2-weighted sequence with fat suppression. A paralabral cyst is identified (short arrows) which extends into
the spinoglenoid notch region. Note the atrophy of the infraspinatus muscle (long arrows in A).
usually with extension of the posterior cyst into the
spinoglenoid notch. Cysts that cause nerve compression
are usually large (mean size 3.1 cm). Infraspinatus muscle
atrophy may be seen (Fig. 99-73). Compression of the
axillary nerve may be an unusual cause of quadrilateral
space syndrome.390 Atrophy of the teres minor muscle
may also be seen.
Glenoid Labrum Articular Disruption
Another recently described lesion occurs in athletes and
has been described at arthroscopy.391 The GLAD lesion
(glenoid labrum articular disruption) is a tear of the
superficial anterior inferior labrum and also involves
articular cartilage (Fig. 99-74). It results from a forced
adduction across the chest from an abducted and
externally rotated position. The labral tear is an inferior
flap-type tear. It is not associated with glenohumeral
instability. In addition, there is fibrillation and erosion of
the articular cartilage in the anteroinferior quadrant of
the glenoid fossa. These lesions may be visible on MRI
and MR arthrography may improve the sensitivity to
these lesions.392,393
Glenohumeral Internal Rotation
Deficit in Abduction
This refers to the concept proposed by Burkart and
Morgan295,374,394 that reflects the fact that many of the
problems associated with shoulder disability in older
throwing athletes is due to contracture and thickening of
the posterior inferior capsule, which results in a
glenohumeral internal rotation deficit in abduction
C H A P T E R 99 ■ S HOULDER 3259
(GIRD). This is associated with secondary hyper-
external rotation. Other associated lesions include the
posterior peel back lesion of the glenoid labrum
from the biceps tendon insertion to the posterior supe-
rior labrum,324,394,395 SLAP type 2 lesions, and dead arm
syndrome.374 Shear and torsional forces result in
injury to the posterosuperior aspect of the rotator cuff.
Although lesions similar to those described in posterior
superior glenoid impingement are seen, the posterior
inferior capsular lesion rather than the act of subglenoid
impingement is considered to be the underlying cause.
The anterior capsular stretching, often seen in older
throwing athletes, is also considered to be secondary to
the posterior capsular contracture. These lesions,
including the presence of posterior capsular thickening,
may be best outlined with MRI arthrography (Fig. 99-75).
POSTOPERATIVE SHOULDER
Imaging the postoperative shoulder is challenging both
from an imaging point of view and a technical point of
view.396-405 Certain technical factors must be taken into
consideration. Postoperative artifact is problematic in
imaging the postoperative patient. This includes ferro-
magnetic screws or staples. Small metal shavings from
the use of a burr during acromioplasty may yield con-
siderable artifact. The use of gradient-echo sequences
should be minimized and fast spin-echo imaging is
useful to minimize the degree of magnetic susceptibility
artifact. Additionally, fat saturation may be incomplete
and fast spin-echo inversion recovery sequences may be
more useful. MR arthrography can be a useful tool to
help image postoperative patients more successfully.
099.qxd 17/6/05 12:56 PM Page 3260
3260 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
A B
F I G U R E 99-74
Glenoid labrum articular disruption (GLAD) lesion. A and B, Axial 2D gradient-echo images. There is a tear of the
anterior inferior labrum (arrow in B). It is associated with an osteochondral-like lesion of the inferior anterior margin
of the glenoid articular surface (arrow in A). The capsuloligamentous structures are intact.
Impingement and Rotator Cuff Disease
Subacromial Decompression
without Rotator Cuff Repair
Surgical Technique
The first category of postoperative patients is those who
have had a prior acromioplasty for impingement with an
intact rotator cuff and no rotator cuff repair. This
procedure may be done open, via an anterolateral deltoid
splitting incision, or via arthroscopy. The anteroinferior
acromion is removed, from the acromioclavicular joint to
the deltoid insertion, removing that portion anterior to
the clavicle. Most often the subdeltoid bursa is also
resected as well as a variable part of the coracoacromial
ligament. The acromioclavicular joint and the distal
2.5 cm of the clavicle may also be removed.
MRI Findings
MRI findings associated with acromioplasty include a
flattened acromial undersurface, nonvisualization of the
anterior one third of the acromion, and decreased
marrow signal in the remaining distal acromion due to
marrow fibrosis. Low signal due to artifacts from small
metal fragments are often present, related to burring of
the acromion. Removal of the subacromial bursa and
subdeltoid fat pad results in the absence of these
structures on postoperative studies, and most often a
small amount of fluid signal on images with T2
contrast. If the acromioclavicular joint has been excised,
scar tissue may be the most prominent finding (Fig.
99-76).397,400,403,405
Causes of persistent pain after subacromial decom-
pression include inadequate acromioplasty and residual
osteoarthrosis of the acromioclavicular joint (Fig. 99-77).
Sagittal oblique MR images evaluate the adequacy of the
decompression and any persistent impingement due to
insufficient acromion resection or the persistence of a
large subacromial spur. Large osteophytes projecting
from the acromioclavicular joint may be seen on coronal
and sagittal images. After acromioplasty, there may be
progression of rotator cuff disease, including the inter-
val development of a rotator cuff tear, partial or com-
plete (Fig. 99-77). Unrecognized partial tears or small
complete tears may extend. Progression may occur if
the acromioplasty and decompression are inadequate,
with persistent subacromial roughening.397,400,403,405
In the setting of interval development of a cuff tear or
extension and/or progression of existing cuff pathology,
such as tendinosis, the integrity of the cuff is more
difficult to determine in the postoperative situation. MRI
remains sensitive but less specific than MRI without
prior surgery. Criteria include a definite region of dis-
continuity in the cuff, accompanied by fluid signal on
images with T2 contrast, STIR or T2*-weighted gradient-
echo sequences, or when contrast extravasation is seen
through the cuff defect at MR arthrography (see Fig.
99-77).397,400,403,405
Rotator Cuff Repair or Debridement
Surgical Technique
The second category involves patients who have had a
prior rotator cuff repair. In patients with partial-thickness
tears, treatment depends on the area, depth, and severity
099.qxd 17/6/05 12:56 PM Page 3261

C H A P T E R 99 ■ S HOULDER 3261

A B

C D
F I G U R E 99-75

Glenohumeral internal rotation deficit (GIRD). A, Axial T1-weighted MR arthrogram. Note the thickened post
capsule at the site of insertion into the glenoid (arrow). B, Coronal oblique T1-weighted MR arthrogram in the same
patient as in A. Note the alterations in the posterior rotator cuff (long arrow), the degenerative-type tear of
the posterior superior labrum (short arrow), and the cystic changes in the humeral head (arrowhead). C, Axial
T1-weighted MR arthrogram in a different patient. Note the thickened posterior capsule, similar to that in A (arrow).
D, Axial T1-weighted MR arthrogram in the same patient as in C. Note the superior labrum anterior posterior
(SLAP) type 2 tear of the superior labrum (arrows).

of tendon involvement. Treatment may vary from
debridement of frayed tissue in more superficial partial
tears, to completely excising the area of the partial
defect and repairing the defect as if it were a small full-
thickness defect. Repairs of high-grade partial- or
full-thickness tears are either a side-to-side or tendon-to-
bone repair and may be accompanied by decom-
pression. This may be done arthroscopically, open, or
with a combined approach.
MRI Findings
MRI findings following cuff repair (Fig. 99-78) include
distortion of the soft tissues adjacent to the cuff and
nonvisualization of the subdeltoid fat/bursa and fluid in
the region of the subdeltoid bursa. Soft-tissue metal or
suture artifacts occur due to nonabsorbable sutures and
suture anchors, especially if ferromagnetic suture
anchors are used. Granulation tissue surrounding sutures
may result in intermediate or high signal on images with
T2 contrast in the peritendinous tissues. A surgical
trough in the humeral head is present with tendon-to-
bone repairs. Intermediate signal within the rotator cuff
substance may be present due to granulation tissue. Mild
superior subluxation of the humeral head may occur due
to capsular tightening, scarring, cuff atrophy, or
bursectomy. Mild marrow edema in the humeral head
may be seen.397,400,403,405
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3262 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM
A
C an acromioplasty and distal clavicle excision (long arrow).
Fluid signal on T2-weighted images seen within a
recurrent rotator cuff tendon defect or nonvisualization
of a portion of the cuff are the more reliable indicators
of full-thickness tears in the postoperative patient, with
complete absence of the tendon the most specific
finding. In the postoperative situation there may be a
higher incidence of low signal tears due to chronic
granulation tissue. Secondary signs such as muscle
atrophy and tendon retraction may be helpful (Fig.
99-79). MR arthrography can document leakage of
contrast through a cuff defect directly, and the cuff
tissues and tendon edges may be better delineated with
this technique (Fig. 99-80). The location of the musculo-
tendinous junction is not a reliable sign after surgery
because its position may change if the cuff is mobilized
during surgery.397,400,403,405
The criteria for a recurrent partial tear is fluid signal
on images with T2-weighted contrast replacing a portion
of the tendon. Small recurrent full-thickness tears may be
underestimated as partial tears. MR arthrography may
help to resolve these difficulties.397,400,403,405
Deltoid Detachment
Postoperative detachment of the deltoid from its
insertion to the acromion may occur. On MRI images, the
presence of deltoid detachment can be identified by
F I G U R E 99-76
Status post acromioplasty, distal clavicle excision.
A, Coronal oblique proton-density–weighted image. The
anterior portion of the acromion has been removed
(arrow). Also note the low signal post-surgical artifact.
B, Sagittal oblique proton-density–weighted image. The
extent of the decompression is often best seen in this
position. The anterior acromion, acromioclavicular joint,
and distal clavicle have been excised (arrow). C, Coronal
T2-weighted image. Increased signal or fluid is often
identified in the subdeltoid bursal region post decom-
pression, due to accompanying resection or debride-
ment of the bursa. The bursal surface of the tendon is
thin, likely post debridement (short arrow). There has been
retraction of the deltoid from the acromion with fluid
filling the defect.397,406,407 If the detachment is chronic,
atrophy will be present.
Biceps Tendon Rupture
MRI is accurate in the diagnosis of biceps tendon
rupture in patients after surgery. This is diagnosed by
lack of visualization of the biceps tendon in the inter-
tubercular groove.
Shoulder Instability
Surgical Approach
The surgical treatment of patients with anterior
instability has involved different approaches. Most
commonly a direct repair of the labral and capsular
lesions is done, usually a Bankart-type repair, or less
commonly staple capsulorraphy. Other types of repair
are those that tighten the capsule indirectly, usually
through manipulation of the subscapularis, most com-
monly the Putti Platt or Magnusson-Stack procedure, and
those that involve movement of the coracoid process,
most commonly the Bristow procedure.
099.qxd 17/6/05 12:56 PM Page 3263

C H A P T E R 99 ■ S HOULDER 3263

F I G U R E 99-77

Postacromioplasty pain. A, Coronal oblique T2-weighted

fast spin-echo sequence with fat saturation. There is
persistent acromioclavicular joint arthritis with marginal
edema (long arrow). A small undersurface partial tear is
also seen (short arrow). B, Coronal oblique T1-weighted
MR arthrogram. The patient has had an acromioplasty.
There is an intermediate-grade undersurface partial
thickness tear (arrow). C, Coronal oblique, fast inversion-
recovery sequence in another patient. The patient has
had an anterior acromioplasty. There has been interval
development of a full-thickness tear of the supraspinatus
tendon, anterodistally (arrow).
C

A B
F I G U R E 99-78

Postoperative shoulder. Rotator cuff repair. A and B, Coronal oblique proton-density–weighted images. There has
been a tendon-to-bone repair (short arrows). Note the bone trough for the sutures (arrowhead in B). There has been
an acromioplasty (long arrow in A).
099.qxd 17/6/05 12:56 PM Page 3264

3264 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

F I G U R E 99-79

Recurrent rotator cuff tear. Coronal oblique A, proton-

density– and B, T2-weighted fast spin-echo sequence
with fat saturation. There is a recurrent full-thickness
tear (long arrows). The tendon is retracted medially with
thin edges. Note the site of repair (short arrows). There is
persistent subacromial spur formation and acromoclav-
icular joint osteoarthritis. C, Sagittal oblique T1-weighted
images. Note the muscle atrophy and fat infiltration
(arrows).

F I G U R E 99-80

Coronal oblique T1-weighted MR arthrogram. A mod-

erate size recurrent tear of the supraspinatus tendon is
identified (arrow). Depiction of the tear size and status of
the tendon edges is aided by MR arthrography.
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C H A P T E R 99 ■ S HOULDER 3265

Normal Postoperative MRI Findings
The artifacts from surgery impair visualization, including
metal and suture artifacts, especially screw fixation of
the coracoid in the Bristow procedure, or the placement
of suture anchors, staples, or tacks. Scarring from
the incisions as well as suture repair may impair
visualization. In Bankart repairs (Fig. 99-81) even
nonferromagnetic suture anchors may be apparent
within the glenoid neck. If transglenoid sutures are
placed, channels will be seen traversing the glenoid
neck and scapula. In addition the suture knot placed
posteriorly, i.e., tied over fascia, may show some
surrounding intermediate or high signal on images with
T2-type contrast due to hyperemic granulation tissue. In
patients with anatomic repairs, such as the Bankart
repair, there should be an anatomic position and
morphology of the labrum and capsule post repair. In
procedures that do not directly repair the labral and
capsular lesions, as noted earlier, the abnormality from
these lesions remains.396,397,408
Recurrent Lesions
Causes of recurrent instability (Fig. 99-82) include
inadequate or incorrect procedures and the uncovering
of missed anterior or posterior instability with isolated
treatment of one. An overtight repair can lead either to
degenerative change or may precipitate instability in
the other direction. This may be more common in
procedures such as the Putti Platt or Magnusson-Stack,
which may also result in loss of external rotation. Inferior
capsular shifts or other types of capsular plications can
also be overtightened. Signs of an overtightened inferior
capsular shift include loss of the axillary pouch and
subtle posterior subluxation of the humeral head relative
to the glenoid. Degenerative arthritis may also occur if
there is persistent instability from inadequate repair.
Misplaced or detached staples, tacks or anchors (Fig.
99-83) from labral and capsular repairs or misplaced
screws or coracoid nonunion in a Bristow procedure
may also cause joint derangement. If left unrecognized it
may lead to degenerative changes as well.
In patients after repair of the labrum and capsule the
postoperative labrum may be thickened and irregular
due to scar tissue or suture material, but should not
be detached. Signal alterations may be present post-
operatively and high signal on images with T2 contrast
may be present in the earlier postoperative periods due
to hyperemic granulation tissue.399 As such, outlining
the labrum and capsule with intra-articular contrast
is the best means of discerning recurrent tears and
detachments, by outlining any surface irregularities
and revealing any contrast extension into or beneath
the labrum.401,409 Failed Bankart repairs may show
persistence or recurrence of the detached labrum
and capsule. This may occur due to breakdown of the
fixation from suture breakage, anchor device pullout,
or failure of the reapproximated labral and capsular
tissues. The repaired labrum may also become blunted,
attenuated, or fragmented.
Postoperatively the joint capsule may appear thick-
ened and nodular. Measurements of capsular thickening
have been described for adhesive capsulitis,410 and
can be measured best in the axillary recess on MR

A B
F I G U R E 99-81

Post Bankart repair. A, Axial turbo spin-echo T2-weighted image. Note the artifact from the suture anchor in the
anterior inferior glenoid (short arrow). Low signal from scarring of the labroligamentous tissue is noted after surgery
(long arrows). B, Sagittal oblique fast spin-echo proton-density–weighted image in another patient. Post-surgical
artifact outlines the sites of fixation in the anterior glenoid (arrows).
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3266 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-82

Post Bankart repair. Recurrent lesion. A and B, MR arthrogram. Axial T1-weighted images with fat suppression
(B is inferior to A). The anterior inferior labrum is detached (white arrow in A). Note is also made of early gleno-
humeral joint degenerative change. Note the small osteophytes projecting from the humeral head in A (black arrows).
There is bone loss along the inferior glenoid (arrow in B). A Hill-Sachs lesion is present (arrowhead in A).

arthrography as a band of low signal adjacent to the

hyperintense signal of contrast medially, and the hyper-
intense signal of the fat stripe laterally on T1-weighted
images. A measurement of 4 mm indicates adhesive
capsulitis and one of 2 to 4 mm is considered consistent
with the thickening expected after Bankart repair. The
glenohumeral ligaments may also appear thickened and
nodular post repair. In patients with recurrent instability
the repaired capsule may become stretched and
redundant. These changes are best identified by MR
arthrography. Rand 401 indicates that an anterior capsular
width/posterior capsular width ratio of less than 1 on
MR arthrography may predict a good outcome post sur-
gery, particularly if a capsulorraphy, open or arthroscopic,
has been done. The glenohumeral ligaments, if abnormal,
may appear thin, elongated, irregular, and discontinuous.

OTHER DISORDERS
Occult Fractures
Occult fractures of the proximal humerus often involve
the greater tuberosity and occur as a result of injuries
such as seizures, glenohumeral dislocations, and forced
abduction. Mason et al170 described the MRI findings of
occult greater tuberosity fractures in 12 patients in
whom plain films failed to demonstrate minimally
displaced fractures. All patients had partial tears or
tendinosis of the rotator cuff, but none had full thickness
tears. These authors postulate that the presence of a
fracture precludes a full-thickness tear of the cuff.
Conversely, Zanneti et al411 found nondisplaced greater
tuberosity fractures in 9 of 24 patients following acute
F I G U R E 99-83
Displaced anchor. Sagittal oblique T1-weighted MR arthrogram with fat
suppression. Note the displaced suture anchor (arrow) from a prior Bankart
repair (arrowhead) in the posterior inferior joint recess.
substantial trauma to the shoulder associated with
complete tears of the supraspinatus, infraspinatus, and
subscapularis tendons.411
MRI demonstrates the fracture line as a low signal
irregular area surrounded by bone marrow edema (Fig.
99-84). Clinically, these patients present with symptoms
that simulate rotator cuff tears.
099.qxd 17/6/05 12:56 PM Page 3267

C H A P T E R 99 ■ S HOULDER 3267

A B
F I G U R E 99-84

Occult greater tuberosity fracture. A, Coronal oblique proton-density image and B, T2-weighted image. A linear
region of low signal represents the fracture line (curved black arrows). There is adjacent marrow edema. There is
evidence of injury (strain or contusion) to the cuff and fluid in the bursa (white arrows), but no cuff tear.

A B
F I G U R E 99-85

Pectoralis major rupture. A, Axial T1-weighted image. In the acute phase the muscle rupture is manifested by and
obscured by a focal hematoma. Note the high signal mass (arrows). B, Axial T2-weighted fast spin-echo image with
fat saturation. The retracted torn pectoralis muscle and tendon are now evident (arrows). H, humerus; P, pectoralis
major muscle.

Muscle Injuries
Muscle contusions, hematomas, and ruptures may
involve the muscles of the shoulder girdle, not only the
rotator cuff muscles such as the subscapularis, but also
the surrounding musculature such as the deltoid,
trapezius, or pectoralis muscles.412-414 Muscle hematomas
may have high signal intensity on both T1- and
T2-weighted images (Fig. 99-85). Complete rupture of
the muscles of the shoulder girdle such as the deltoid,
pectoralis, or triceps are relatively uncommon lesions.
Evaluation of pectoralis major ruptures with MRI (Fig.
99-85) has been described.415-418 This occurs most
commonly in weightlifters. Fat-saturated T2-weighted fast
spin-echo sequences in the axial plane with surface coils
are the most useful in diagnosing this lesion and its
extent. Surgical repair of these lesions is difficult but it
is likely that MRI can be very helpful if surgery is
contemplated, to assess the extent, type, and pattern of
rupture, and determine the status of the torn muscle and
tendon edges.
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3268 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

arthritis of the shoulder and can be documented on

Inflammatory and Degenerative
Joint Processes
Many forms of inflammatory and degenerative joint
processes involve the shoulder. These include rheuma-
toid arthritis, ankylosing spondylitis, other seronegative
spondyloarthropathies, and degenerative arthritis.419-423
Involvement of the shoulder is not uncommon in
rheumatoid arthritis and its variants, particularly in long-
standing disease. Osseous erosions occur predominantly
on the humeral side of the joint. The acromioclavicular
joint is also often involved.197 Inflammatory arthritis may
also affect the surrounding bursae, muscles, and rotator
cuff tendons.388,424,425 Although loss of articular cartilage
and osseous erosions may be observed with conven-
tional radiography, they may be visualized at an earlier
stage with MRI and their extent may be better assessed.
Soft-tissue changes, including rotator cuff atrophy and
tears, inflammation of the subacromial bursa, ruptures of
the biceps tendon, and synovial cysts can also be
identified with MRI.419,421,425,426 MRI can be used to
follow patients to assess the response to medical therapy.
Intravenous gadolinium injection is useful in differen-
tiating a joint effusion from acutely inflamed synovium
(Fig. 99-86).426
In septic arthritis MRI may be particularly useful in
establishing an early diagnosis and determining the
extent of the disease. This is important as septic arthritis
in the shoulder in adults rarely responds well to treat-
ment. Early joint aspiration still needs to be performed
for definitive diagnosis and to obtain fluid for culture.
Tears of the rotator cuff may be associated with septic
MR images. This is likely related to erosion of the infe-
rior aspect of the tendon by inflamed synovium. The
presence of a cuff tear may be more responsible for a
poor functional result after treatment than damage to
the articular cartilage. MRI may also be helpful in
documenting extra-articular spread of infection, such as
cavities that may communicate with the joint space.
When osteomyelitis develops, MRI407 will show marrow
edema on short TR/TE, fast spin-echo T2-weighted
images with fat suppression, or STIR images.
Degenerative arthritis in the absence of prior trauma,
or an underlying systemic disorder, is uncommon in the
shoulder (see Fig. 99-86). Changes observed include joint
space narrowing, sclerosis of the subchondral bone and
cyst formation that involves the glenoid and humeral
head. Osteophytes may be seen at the circumference of
the glenoid fossa, along the inferior aspect of the
humeral head and adjacent to the bicipital groove. MRI is
rarely required to assess patients for this clinical problem
alone, but may on occasion be found on imaging patients
with shoulder pain suspected of other disorders.
Degenerative joint disease of the acromioclavicular joint
is very common, particularly in older patients. It may
contribute to rotator cuff disease and shoulder impinge-
ment, but may also be a source of shoulder pain.
Ganglion cysts may develop in relation to this joint.
Other synovial processes, such as pigmented
villonodular synovitis (PVNS) or synovial osteochon-
dromatosis, may be visualized with MRI. The shoulder is
the fourth most common site of involvement of PVNS,
but is still a rare site of involvement.427,428 On MRI,
nodules and villous projections of synovium which

A B
F I G U R E 99-86

Osteoarthritis. Intravenous gadolinium, synovitis. A, Coronal oblique T2-weighted image. Severe joint space
narrowing, subchondral sclerosis, and osteophytes are present. There is a massive subdeltoid bursal effusion.
B, Coronal oblique T1-weighted image after intravenous gadolinium injection with fat saturation. Areas of
enhancement in the joint and bursa represent acutely inflamed synovium superimposed on the degenerative process
(arrows).
099.qxd 17/6/05 12:56 PM Page 3269
contain hemosiderin are seen as areas of intermediate
signal intensity on all pulse sequences. There is usually a
large joint effusion and periarticular cysts may develop.
Cystic erosions may be evident as well-defined areas of
low signal intensity on short TR/TE images and increased
signal intensity on long TR/TE images. Hemosiderin
deposition is more apparent on gradient-echo sequences
because of increased susceptibility effects.
Idiopathic synovial osteochondromatosis (SOC) is a
chronic, progressive, monoarticular disorder caused
by metaplasia of the synovial membrane, with the for-
mation of numerous cartilaginous intra-articular nodules.
Shoulder involvement is less common than that of the
hip and knee.429 MRI can be helpful in verifying
the diagnosis and can demonstrate the nodules, even if
these are not calcified.430-432 Calcified nodules appear
as areas of low intensity on short TR/TE, proton-
density–weighted, and long TR/TE images (Fig. 99-87).
Nodules that do not calcify should have a high signal on
long TR/TE images due to the abundant water content of
hyaline cartilage, with interspersed areas of low signal
due to fibrous tissue between the cartilage nodules. The
surrounding tissue may include areas of inflamed and/or
hyperplastic synovium and reactive fluid.
Osteocartilaginous loose bodies are usually fragments
of bone and cartilage that may be sheared off the glenoid
or humeral head, often secondary to osteochondral
fractures. Other causes of loose bodies include osteo-
arthritis and neuropathic disease. Osteocartilaginous
loose bodies may occur in the joint of patients with
recurrent shoulder dislocations. These may result from
Hill-Sachs lesions or may be fragments from fractures of
the glenoid rim. Clinically, they may cause recurrent
effusions, a locking or grating sensation, as well as a
decreased range of motion. More commonly, they fall
into the inferior capsular recess and do not produce any
A B
F I G U R E 99-87
Synovial osteochondromatosis. A, Coronal oblique T2-weighted fast spin-echo image with fat saturation and
B, axial gradient-echo image. Numerous small and large calcified nodules appear as areas of low signal intensity.
C H A P T E R 99 ■ S HOULDER 3269
significant problem. In general, MRI is not the procedure
of choice to identify loose bodies. When encountered,
densely calcified loose bodies on MRI appear as low
signal intensity structures.When ossified they may be of
high-to-intermediate signal with a low signal intensity
rim due to the presence of mature marrow elements
within. MRI arthrography may be helpful to outline some
of these lesions by distending the joint and by improving
overall contrast resolution.
Osteochondral Lesions
Osteochondral lesions of the shoulder are rare. Different
names and descriptions have been used by different
authors to describe a group of lesions that involve the
articular surface of the glenoid fossa, including osteo-
chondritis dissecans (OCD),433 subchondral avascular
necrosis,434 juxta-articular bone cyst or post-traumatic
subchondral cyst,435 and glenoid articular rim divot
(GARD).370,371,436 These lesions may be related to acute
trauma and are often associated with glenohumeral
instability, labral tears, and intra-articular loose bodies
(Fig. 99-88).433 Cystic changes in the subchondral bone
of the glenoid fossa are the most frequent feature.
Occasionally, loose bodies are found. Careful attention to
the articular surface of the glenoid may reveal the
presence of a chondral or osteochondral defect.
The glenoid articular rim divot (GARD) has been
described based on arthroscopic findings.370,371 MRI
examination in these patients may reveal the chondral
defect as well as a cartilaginous loose fragment in a joint
recess. A similar entity was reported by Chan et al437 in
which multiloculated subchondral cysts are present in
the posterior superior quadrant of the glenoid fossa.
These authors used the same acronym, GARD, to indicate
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3270 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-88

Osteochondral lesion (OCD). A, Axial and B, coronal oblique T2-weighted fast spin-echo MR arthrogram with fat
saturation. Note the osteochondral lesion in the anterior inferior glenoid (arrows). There is a loose body in the
subscapularis bursa (arrowhead in A). The labrum is blunted and torn (thin white arrow in A).

glenoid articular rim disruption. The specific location of
these lesions is thought to be related to a develop-
mentally weak area of the glenoid fossa at an area of
junction between the ossification centers of the glenoid.
These osteochondral lesions are often detected in the
throwing athlete.
high signal intensity representing regions of isolated
marrow fat, surrounded by bands of low signal intensity
representing fibrosis and or calcification in subacute
or chronic infarcts, or a subjacent band of high signal
intensity representing reactive granulation tissue in more
acute infarcts.

Avascular Necrosis Quadrilateral Space Syndrome

This entity results from a significant decrease or loss of
the blood supply to the affected region. The most
common cause is trauma. Other causes such as steroid
use may be implicated. Avascular necrosis may occur
in patients receiving high doses of corticosteroids,
though it is only one third as common as femoral head
avascular necrosis.438,439 The vessels that supply the
humeral head pierce the bony cortex just distal to the
anatomic neck. Fractures proximal to this level, most
commonly involving the anatomic neck, may result in
ischemic necrosis of the humeral head (Fig. 99-89). The
MRI findings in osteonecrosis of the shoulder appear as
focal subarticular regions of decreased signal intensity
(79%) or as a dark signal intensity band surrounding
more normal marrow fat (21%).440 A double line sign,
similar to what has been described in the femoral head,
may be seen (Fig. 99-89). Chronic osteonecrosis demon-
strates an increase in dark fibrosis-like marrow signal,
often complicated by fragmentation and collapse of the
articular surface. Areas of infarction in the diaphyseal
and metadiaphyseal are completely surrounded by a
reactive interface and may have a more geographic or
doughnut appearance.440 There are central regions of
Another entity whose diagnosis on MRI has been
recently described is the quadrilateral space syndrome.
This refers to impingement of the axillary nerve in the
quadrilateral space. This is a space bounded by the teres
minor muscle superiorly, the long head of triceps
medially, the teres major inferiorly, and the surgical neck
of the humerus laterally. The posterior humeral
circumflex artery and axillary nerve course here and
may be entrapped by fibrous bands in this region.
Proximal humeral and scapular fractures or axillary
mass lesions can result in damage or compression of the
axillary nerve. Injury to the nerve may also occur after
anterior dislocation. Entrapment of this nerve can also be
produced by extreme abduction of the arm during
sleep, hypertrophy of the teres minor muscle in
paraplegic patients, or by a fibrous band within the
quadrilateral space.441,442 In advanced cases, atrophy of
the deltoid and teres minor muscles can occur. A
paralabral cyst has been noted as a rare cause of
quadrilateral space syndrome.390
The axillary nerve can be visualized on sagittal oblique
MR images. Osseous lesions involving the axillary nerve
may be better seen with plain film radiography or CT.
099.qxd 17/6/05 12:56 PM Page 3271

C H A P T E R 99 ■ S HOULDER 3271

A B

F I G U R E 99-89

Avascular necrosis (AVN). A, Coronal T1-weighted image.

A focal subarticular region of decreased signal intensity
is seen (arrow), reflective of AVN. B, Coronal oblique
T1-weighted image. This patient has a fracture of the
humeral neck (white arrow). A dark signal intensity band
surrounding more normal marrow fat is seen in the
humeral head (curved black arrow) indicating AVN.
C, Sagittal oblique T2-weighted image in the same patient
as in B. A double line sign, similar to that described in
AVN of the femoral head, is seen (curved black arrow).
The displaced humeral neck fracture is again noted (white
arrow). (Courtesy of Charles Hecht-Leavitt MD, Virginia
Beach, VA.)

Soft-tissue lesions can be detected with MRI. Selective
atrophy or edema of the teres minor muscle and less
commonly the deltoid caused by axillary nerve com-
pression may be identified (Fig. 99-90).443,444
Parsonage-Turner Syndrome
Parsonage-Turner syndrome, also referred to as acute
brachial neuritis, is characterized by the sudden onset of
severe atraumatic pain in the shoulder girdle.445 The
pain typically decreases spontaneously in 1 to 3 weeks
and is followed by weakness of at least one of the
muscles about the shoulder. The exact etiology has not
been established but viral and immunologic causes have
been considered.
Originally the long thoracic nerve was thought to be
most frequently compromised, but suprascapular
nerve disease may be more common. The axillary, radial,
and phrenic nerves may also be affected as well as
the entire brachial plexus. Bilateral involvement may
be present.
MRI findings in the acute stage include diffuse
increased signal intensity on T2-weighted images con-
sistent with interstitial muscle edema associated with
denervation (Fig. 99-91). The most commonly affected
muscles are those innervated by the suprascapular
nerve, including the supraspinatus and infraspinatus.
The deltoid muscle can also be compromised in cases of
axillary nerve involvement. Later in the course of the
disease, muscle atrophy manifested by decreased muscle
bulk may be visualized.239,446
This disorder can resemble a variety of other clinical
diagnoses, but the most confusing differential diagnosis
is compressive neuropathy of the suprascapular nerve.447
MRI can exclude suprascapular nerve entrapment
related to paralabral ganglions or other impinging mass
lesions.239,446,448 Rotator cuff pathology can also be
readily excluded using MRI.
099.qxd 17/6/05 12:56 PM Page 3272

3272 S E C T I O N VII ■ M USCULOSKELETAL S YSTEM

A B
F I G U R E 99-90

Quadrilateral space syndrome. A, Coronal short tau inversion recovery (STIR) and B, axial T2-weighted fast spin-
echo images. Patient sustained an anterior dislocation. Note the Hill-Sachs lesion in B (black arrow). There is
denervation edema in the deltoid and teres minor muscles (white arrows).

A B
F I G U R E 99-91

Parsonage Turner syndrome. A, Axial short tau inversion recovery (STIR) and B, sagittal oblique T2-weighted images.
Increased signal intensity consistent with interstitial muscle edema associated with denervation is seen in the
supraspinatus and infraspinatus muscles (arrows).
099.qxd 17/6/05 12:56 PM Page 3273
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