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Estimating the Dimensions of the Rotator Interval with Use of Magnetic

Resonance Arthrography
Kyung-Cheon Kim, Kwang-Jin Rhee, Hyun-Dae Shin and Young-Mo Kim
J Bone Joint Surg Am. 2007;89:2450-2455. doi:10.2106/JBJS.F.01262

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BY

THE JOURNAL

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BONE

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Estimating the Dimensions of the Rotator Interval

with Use of Magnetic Resonance Arthrography
By Kyung-Cheon Kim, MD, Kwang-Jin Rhee, MD, Hyun-Dae Shin, MD, and Young-Mo Kim, MD
Investigation performed at the Department of Orthopaedic Surgery, Chungnam National University College of Medicine, Daejeon, South Korea

Background: The goal of the present study was to define the dimensions of the normal rotator interval with magnetic
resonance arthrography and to compare these dimensions with those in shoulders with known chronic anterior instability in order to determine if abnormalities of the rotator interval might be better understood and estimated preoperatively.
Methods: We retrospectively reviewed a consecutive series of 202 shoulders that had undergone magnetic resonance arthrography between 2004 and 2005. Of these, 120 shoulders were included in the present study. These
shoulders were divided into two groups according to the diagnosis. Group I comprised fifty shoulders with no instability, and Group II comprised seventy shoulders with chronic anterior instability. With use of magnetic resonance arthrography, the base and height of the rotator interval and the diameter of the glenoid were measured. Then, the area
of the rotator interval and the rotator interval index were calculated.
Results: In Group I, the mean estimated rotator interval dimensions (height and base), the mean calculated rotator
interval area, and the mean rotation interval index were 16.73 mm, 48.59 mm, 406.47 mm2, and 0.64, respectively.
In Group II, these values were 21.87 mm, 49.40 mm, 540.06 mm2, and 0.94, respectively. The shoulders in Group II
differed significantly from the shoulders in Group I in terms of rotator interval height, rotator interval area, and rotator
interval index (p < 0.01 for all).
Conclusions: There are significant differences in the dimensions of the rotator interval between patients with and
without recurrent anterior shoulder instability. Estimating the dimensions of the rotator interval with use of magnetic
resonance arthrography may be valuable for assessing patients preoperatively.

he concept that the rotator interval is a distinct anatomic area with the potential for distinct pathological
changes in cases of glenohumeral instability is relatively
new. The understanding of the role of the rotator interval in
shoulder mechanics continues to evolve, as does the treatment
of pathologic conditions that may affect it1. The routine evaluation of shoulder instability often entails magnetic resonance arthrography, which is indicated mainly to assess the labrum. In a
cadaver study, Chung et al.2 demonstrated the normal rotator
interval anatomy with use of magnetic resonance arthrography,
which was found to be superior to nonarthrographic magnetic
resonance imaging for depicting those structures. The dimensions of the rotator interval could be determined on sagittal
magnetic resonance arthrographic images, whereas the coracohumeral ligament was seen inconsistently and the superior
glenohumeral ligament was not clearly identified on nonarthrographic magnetic resonance images.

Several studies have evaluated the dimensions of the rotator interval on the basis of direct measurement of dissected
cadaveric specimens3,4. To our knowledge, no studies have
evaluated normal rotator interval dimensions with use of
magnetic resonance arthrography. Therefore, in the present
study, we defined the dimensions of the normal rotator interval with use of magnetic resonance arthrography and compared these values with those in shoulders with known
recurrent anterior instability in order to determine if abnormalities of the rotator interval might be better detected and
measured preoperatively.
Materials and Methods
Clinical
e retrospectively reviewed the records for a consecutive
series of 202 shoulders that had undergone magnetic
resonance arthrography between 2004 and 2005. Of these, 120

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a
member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial
entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2007;89:2450-5 doi:10.2106/JBJS.F.01262

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shoulders in 118 patients (including ninety-nine male patients

and nineteen female patients) who had a mean age of 32.3
years (range, fifteen to sixty-five years) were included in the
present study. The shoulders were divided into two groups according to diagnosis. Group I comprised fifty shoulders with
no instability in patients who ranged from twenty-two to
sixty-five years of age, and Group II comprised seventy shoulders with recurrent anterior instability in patients who ranged
from fifteen to twenty-four years.
Group I included patients who had an otherwise normal
shoulder on magnetic resonance arthrography (nineteen shoulders), those who had rotator cuff tendinitis (twenty-four
shoulders), and those who had a partial-thickness rotator cuff
tear that involved less than half of the thickness of the supraspinatus or infraspinatus tendon (seven shoulders) without limitation in the range of motion. We excluded patients
who had conditions of the shoulder in which the intra-articular
volume or pressure may have changed as a result of shoulder
pathology, such as rotator cuff tendinitis (eight shoulders) and
partial-thickness rotator cuff tears (five shoulders) with limitation of the range of motion, partial-thickness rotator cuff
tears that involved more than half of the thickness of the supraspinatus or infraspinatus tendon (seven shoulders), fullthickness rotator cuff tears (eleven shoulders), ruptures of the
rotator interval (one shoulder), adhesive capsulitis (twelve
shoulders), and avulsion fractures of the greater tuberosity of
the humerus (two shoulders).
Group II included seventy shoulders with chronic traumatic or atraumatic anterior instability. We excluded patients
with instability in any direction other than anteriorly (three
shoulders), patients with only one episode of instability (nine
shoulders), patients with a lack of chronic symptoms lasting
for more than six months (thirteen shoulders), and patients
with a history of a previous shoulder surgical procedure (three
shoulders). Patients with only one episode of instability were
excluded because first-time dislocation does not always
progress to recurrent instability, although widening of the rotator interval was seen in some. In addition, one patient who
had a concomitant full-thickness rotator cuff tear was excluded. Seven shoulders were excluded because of inadvertent
injection of air bubbles or definite extravasation of contrast
medium through the joint as identified on magnetic resonance arthrography. Although there were no large osseous
Bankart lesions and no cases of osteoarthritis in the present
study, either finding would have been considered an exclusion
criterion.
Magnetic Resonance Arthrography Technique
Magnetic resonance arthrography was performed for all patients. A 20-gauge spinal needle was used to access the glenohumeral joint through an anterior approach under fluoroscopic
observation. One milliliter of iodinated contrast agent (Telebrix; Guerbet, Aulnay-sous-Bois, France) was used to verify
the intra-articular position. Subsequently, 12 mL of a solution
consisting of 1 mL of gadolinium dimeglumine (Magnevist;
Schering, Berlin, Germany) diluted in 250 mL of saline solution

E ST I M AT I N G TH E DI M E N S IO N S OF T H E RO TA TOR IN TE R V A L
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were instilled into the glenohumeral joint. Although the

amount of diluted gadolinium that is injected into the shoulder
joint typically ranges from 10 to 20 mL, a larger volume (15 to
25 mL) may be required for patients with a capacious joint
cavity5-7. The diluted gadolinium was injected with gentle pressure, until slight resistance was felt or until the plunger rebounded. The injection was stopped if the patient complained
of a sensation of increased pressure or pain during the
procedure8. One musculoskeletal radiologist performed all solution instillations in all shoulders. Magnetic resonance imaging was performed with use of a 1.5-T clinical system (Signa;
General Electric Medical Systems, Milwaukee, Wisconsin) with
a 5-in (12.7-cm) general-purpose flexible coil. Magnetic resonance arthrography was performed with the arm at the side in
neutral rotation; we relied on the patient to maintain the position during the examination. For some patients, small sandbags and tape were used to stabilize the hand in the neutral
position and to reduce shoulder motion artifact.
Radiographic Interpretation
Images were evaluated on the basis of the consensus of two
surgeons who subspecialized in the treatment of shoulder
disorders (K.-C.K. and K.-J.R.), with particular attention to
identifying and evaluating the structures comprising and traversing the rotator interval and capsule on all imaging planes

Fig. 1

The rotator interval was defined as a right triangle, with the height (A)
along the coracoid process (C), the base (B) being the distance along
the subscapularis (SSC) border, and the hypotenuse being the supraspinatus (SST) border. THL = transverse humeral ligament, and
LHB = long head of biceps.

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the superior edge of the subscapularis tendon at the lateral base

of the coracoid. The base of the rotator interval is marked along
the superior border of the subscapularis to the anterior border
of the supraspinatus. This point is consistently located on the
lateral ridge of the biceps sulcus at the superior margin of the
transverse humeral ligament (Fig. 1). The apex of the rotator interval is at the bicipital groove. This triangular space contains
the biceps tendon, the superior glenohumeral ligament, the glenohumeral capsule, and the coracohumeral ligament.
Measurements of the Rotator Interval
The rotator interval was best evaluated after magnetic resonance arthrography in the sagittal plane9. However, without
distending the joint, the space defining the rotator interval be-

Fig. 2

Serial sagittal magnetic resonance arthrographic images of the glenohumeral joint from lateral to medial (left column) and the corresponding
level in the transverse images (right column). The middle sagittal image
is the best sagittal section for measuring the height of the rotation interval. SSC = subscapularis, SST = supraspinatus, IST = infraspinatus,
and C = coracoid process.

in magnetic resonance arthrography. All of the measurements

were performed by one of us (K.-C.K.) and then were repeated
independently by the same individual one month later. All of
the dimensions described below were measured electronically
by applying magnetic resonance arthrography data for the rotator interval with use of PACS (picture archiving and communication system) measurement software (Marotech, Seoul,
Korea).
Fig. 3

Anatomy of the Rotator Interval

The rotator interval is defined by its triangular borders and
their contents3,9. The height of the rotator interval is marked
from the superior edge of the subscapularis tendon at the lateral
base of the coracoid process to the anterior border of the supraspinatus tendon, where it intersects a line perpendicular to

Serial transverse magnetic resonance arthrographic images of the

glenohumeral joint from superior to inferior (left column) and the corresponding level in the sagittal images (right column). The middle
transverse image is the best transverse section for measuring the
base of the rotation interval. SST = supraspinatus, SSC = subscapularis, and C = coracoid process.

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Fig. 4

The height (A) of the rotator interval was measured on the sagittal image from the superior border of the subscapularis to the anterior border of the supraspinatus at the level just anterior to the base of the coracoid process, and the base (B) of the rotator interval was measured on the transverse image from the superior edge of the subscapularis tendon at the lateral base of the coracoid
process to the lateral ridge of the biceps sulcus at the superior margin of the transverse humeral ligament. The glenoid diameter
(D) was defined as the largest transverse diameter of the glenoid intersecting a line perpendicular to the line having the largest longitudinal diameter drawn from the superior glenoid tubercle at the level just anterior to the base of the coracoid process.

tween the tendons of the subscapularis and supraspinatus

muscles was difficult to discern. In addition, it was impossible
to determine the anteroposterior dimension of the rotator interval capsule on sagittal images. In the present study, the
height of the rotator interval was measured on the sagittal image from the superior border of the subscapularis to the anterior border of the supraspinatus at the level just anterior to the
base of the coracoid process; the base of the rotator interval
was measured on the transverse image from the superior edge
of the subscapularis tendon at the lateral base of the coracoid
process to the lateral ridge of the biceps sulcus at the superior
margin of the transverse humeral ligament (Figs. 2 and 3).
Then, the area of the rotator interval was calculated as 0.5
base height. In addition, to evaluate the standardized length
of the height corrected for patient size, the height of the rotator interval (A) was divided by the glenoid diameter (D), and
this value was defined as the rotator interval index. In addition, we defined the glenoid diameter as the largest transverse
diameter of the glenoid intersecting a line perpendicular to
the line with the largest longitudinal diameter drawn from the
superior glenoid tubercle at the level just anterior to the base
of the coracoid process (Fig. 4).

Statistical Analysis
The binary categorical variables, such as the base, height, glenoid diameter, rotator interval area, and rotator interval index,
were compared with use of the independent-samples t test.
The level of significance was set at p < 0.05.
Results
he mean amount of diluted gadolinium injected into the
glenohumeral joint that caused a sensation of fullness was
15.86 mL (range, 7 to 21 mL) in Group I and 18.03 mL (range,
13 to 25 mL) in Group II. In Group I, the mean rotator interval dimensions (height and base) and the mean calculated
area for shoulders in the neutral position were 16.73 mm
(range, 11.37 to 21.40 mm), 48.59 mm (range, 41.25 to 55.96
mm), and 406.47 mm2 (range, 234.51 to 598.77 mm2), respectively. In Group II, these values were 21.87 mm (range, 16.96
to 30.84 mm), 49.40 mm (range, 42.39 to 54.84 mm), and
540.06 mm2 (range, 359.47 to 845.63 mm2), respectively. The
mean rotator interval index was 0.64 (range, 0.44 to 0.87) in
Group I and 0.94 (range, 0.64 to 1.34) in Group II (Table I).
The shoulders in Group II differed significantly from
the shoulders in Group I in terms of the amount of diluted ga-

TABLE I Estimated Rotator Interval Dimensions, Calculated Area, and Rotator Interval Index*

Height (mm)

Base (mm)

Rotator Interval
Area (mm2)

Glenoid
Diameter (mm)

Rotator
Interval Index

Group I

16.73 (11.37 to 21.40)

48.59 (41.25 to 55.96)

406.47 (234.51 to 598.77)

26.16 (21.12 to 31.00)

0.64 (0.44 to 0.87)

Group II

21.87 (16.96 to 30.84)

49.40 (42.39 to 54.84)

540.06 (359.47 to 845.63)

22.91 (19.03 to 26.99)

0.95 (0.64 to 1.34)

*The values are given as the mean, with the range in parentheses.

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dolinium injected, the rotator interval height, the rotator interval area, and the rotator interval index (p < 0.01) but not in
terms of the rotator interval base (p > 0.05). In addition, the
shoulders in Group I had a significantly larger glenoid diameter than did the shoulders in Group II (p < 0.01).
Discussion
n order to understand the pathology of the rotator interval, it is important to realize that any single structure or
combination of structures can be affected1. Magnetic resonance arthrography appears to be a promising modality with
which to evaluate the rotator interval through distention of
the capsule and the depiction of the associated ligaments.
The importance of magnetic resonance arthrography in
identifying these lesions is compounded when one considers
the difficulty of evaluating these structures both clinically
and arthroscopically10.
Estimation of the dimensions of the rotator interval
must be clinically reliable and reproducible by different observers with varying experience levels. Cadaveric studies investigating rotator interval dimensions have been reported in the
orthopaedic literature2,4; however, little has been written concerning the noninvasive measurement of rotator interval dimensions. In a cadaveric study, Chung et al.2 measured the
anteroposterior dimension of the rotator interval capsule on
sagittal magnetic resonance arthrographic images. The capsule was measured at the level of the intra-articular biceps
tendon on an image just lateral to the coracoid process. The
width of the rotator interval capsule ranged from 1.7 to 2.0
mm. Tetro et al.4 measured the dimension from the anterior
edge of the supraspinatus to the superior edge of the subscapularis at the level of the glenoid margin with the humerus in
neutral rotation. The estimated distance was 21.6 mm and increased to 27.8 mm with joint distention. Plancher et al.3 determined the mean rotator interval dimensions (height, base,
and hypotenuse) and area in the neutral position to be 20.96
mm, 39.31 mm, 44.72 mm, and 414.46 mm2, respectively.
Some differences exist between the dimensions reported
in previous cadaveric studies3,4 and those in our magnetic resonance arthrography study. These differences in dimensions
may arise from racial differences and the amount of contrast
medium injected for arthrography. In addition, as opposed to
cadaveric studies, an estimate of the base with use of magnetic
resonance arthrography might be inaccurate if the transverse
section is not parallel to the superior border of the subscapularis muscle. Rotation of the arm is also a very important consideration as the estimation of the base might vary with slight
changes in rotation. To maintain the position of neutral rotation, the use of some type of positioning device would be desirable in a prospective study. While we could control the arm
rotation at the elbow relatively well, we could not control for
variable amounts of retroversion that were inevitably present.
Because we studied a relatively large number of individuals,
the effects of variability in torsion in both the instability and
normal groups might have been balanced, although this was
not confirmed on the basis of our data.

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In the present study, the dimensions of the rotator interval, except for the base and the glenoid diameter, were significantly larger in Group II than in Group I. These results may
have arisen because the base was determined from the rotation of the humerus only. Therefore, instability itself did not
affect the base of the rotator interval. In addition, the glenoid
diameter in Group II might have theoretically been measured
as being much less than that in Group I because of a labral or a
small osseous Bankart lesion, which were frequently seen in
patients in Group II. However, there was only one osseous
Bankart lesion in Group II, and it was not large. The other
shoulders had labral Bankart lesions, with the exception of
two shoulders that had a Hill-Sachs lesion without glenoid labral abnormality. However, because of the almost uniform
appearance of the glenoid labral abnormalities (i.e., labral
Bankart lesions) in Group II, the rotator interval measurements of the patients with a labral Bankart lesion would not
be mistaken for those with an osseous Bankart lesion or without labral abnormalities.
The present study had several limitations. First, the capacity and volume of the joint capsule (i.e., the amount of
contrast medium injected into the glenohumeral joint) varies
widely from patient to patient depending on the clinical circumstances. Therefore, the amount of distention of the rotator interval was not well controlled. In addition, it is
important to consider differences in height, gender, weight,
and body mass index between subjects. Because of the retrospective nature of this review, the height and body weight of
the patients were not evaluated in the present study (except
for patients who were managed surgically), although the
height of the rotator interval was divided by the glenoid diameter to standardize this measurement for patient size. To evaluate the standardized rotator interval dimensions corrected
for gender and patient size, a prospective study should use
specific measures, such as the height, body weight, or body
mass index. Second, our normal control group was not composed of normal healthy shoulders. In addition, it was not
confirmed whether rotator cuff abnormalities in the control
group had contributed to the rotator interval pathology, because there was no arthroscopic evaluation to effectively rule
out associated rotator interval pathology. However, to minimize these effects on the rotator interval according to the clinical circumstances, we selected shoulders that were otherwise
normal on magnetic resonance arthrography without range-ofmotion limitation and shoulders with rotator cuff tendinitis
or a partial-thickness rotator cuff tear without range-ofmotion limitation. In addition, we excluded shoulders with
conditions in which the intra-articular volume or pressure
could have changed as a result of shoulder pathology. Another
limitation was the retrospective nature of the review. Therefore, the dimension measurements in the instability and normal groups were not confirmed with use of an arthroscopic
evaluation. In addition, only one observer measured the rotator interval dimensions, although the images were evaluated
by the consensus of two shoulder surgeons with particular attention being paid to identifying and evaluating the rotator

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interval. Despite these limitations, the present study remains

important because it is the first, to our knowledge, to estimate
the dimensions of the rotator interval with magnetic resonance arthrography and to demonstrate some significant differences among patients with and without chronic anterior
instability.
In conclusion, the rotator interval was defined as a triangle and its mean dimensions were recorded. Patients with
recurrent anterior instability had significant differences from
normal values. An understanding of the normal and pathological anatomy of the rotator interval may be helpful for the
successful diagnosis and treatment of lesions in this region.

E ST I M AT I N G TH E DI M E N S IO N S OF T H E RO TA TOR IN TE R V A L
U S E O F M A G N E T I C R E S O N A N C E A R T H RO G R A P HY

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Estimation of the dimensions of the rotator interval with use

of magnetic resonance arthrography might prove to be valuable for the assessment of patients preoperatively.

Kyung-Cheon Kim, MD
Kwang-Jin Rhee, MD
Hyun-Dae Shin, MD
Young-Mo Kim, MD
Department of Orthopaedic Surgery, Chungnam National University
College of Medicine, 640 Daesa-Dong, Jung-Gu, Daejeon 301-040, South
Korea. E-mail address for K.-C. Kim: kckim@cnuh.co.kr

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