Gerard J.

Kieft, MD Johan
#{149} L. Bloem, MD Willem
#{149} R. Obermann, MD
Abraham J. Verbout, PhD Pieter
#{149} M Rozing, PhD Joost Doornbos,
#{149} PhD

Normal Shoulder: MR Imaging’

Relatively poor spatial resolution T HE shoulder joint has a large shoulder has been limited, partially
has been obtained in magnetic reso- range of motion due to move- because of the relatively poor spatial
nance (MR) imaging of the shoulder ment of the scapula that accompanies resolution obtained when the shoul-
because the shoulder can only be motion at the glenohumeral joint. der is, by necessity, placed in the pe-
placed in the periphery of the mag- The shallow glenoid cavity is small riphery of the magnetic field (radio-
netic field The authors have de- compared with the large humeral frequency [RF] coil). Our study
vised an anatomically shaped sur- head: the area of glenohumeral con- suggests image quality can be im-
face coil that enables MR to tact is only about one-third of the to- proved by the use of a specially de-
demonstrate normal shoulder anato- tal head surface. This small area of signed surface coil for the shoulder.
my in different planes with high contact limits mechanical stability; Use of this coil allows MR to demon-
spatial resolution. In the axial plane, joint stability is therefore highly de- strate normal shoulder anatomy with
anatomy analogous to that seen on pendent on the joint musculature, high spatial resolution in multiple
computed tomographic (CT) scans tendons, ligaments, and cartilage in- planes. A proposal is made for the
can be demonstrated. Variations in cluding the labrum (1-5). Until re- optimal imaging planes of several
scapular position (produced by pa- cently, diagnostic imaging of these clinically important structures.
tient positioning) may make repro- soft tissues has been possible only
ducibility of sagittal and coronal with relatively invasive procedures
MATERIAL AND METHODS
plane images difficult by changing including arthrogmaphy with positive
the relationship of the plane to the and double contrast material en- MR imaging was performed using a
0.5-I superconductive system (Gyroscan,
shoulder anatomy. Oblique planes, hancement (6-10), arthmotomography
Philips Medical Systems, The Nether-
for which the angle is chosen from (1 1-12), computed amthrotomography
lands). The signal-to-noise (S/N) ratio
the axial image, have the advantage (12-13), and bursography (14). Mag-
was increased by using an anatomically
of easy reproducibility. Obliquely netic resonance (MR) imaging is a shaped surface coil specially designed for
oriented structures and relation- new, noninvasive modality that al- the shoulder region (15). The antenna is
ships are best seen in oblique plane lows high-contrast, multiplanar im- flexible and can be adjusted to the size of
images and can be evaluated in de- aging of the shoulder. However, ex- any individual patient (16).
tail. perience with MR imaging of the In ten volunteers, 5-mm-thick section

Index terms: Magnetic resonance (MR), tech-

nology Shoulder,
#{149} anatomy, 414.1 #{149}
Shoulder,
MR studies, 414.1299

Radiology 1986; 159:741-745

1 From the Departments of Diagnostic Rad!-

ology (G.J.K., J.L.B., W.R.O., J.D.), Orthopaedic
Surgery (A.J.V., P.M.R.), and Anatomy (A.J.V.),
University Hospital Leiden, Rijnsburgerweg
10, 2333 AA Leiden, The Netherlands. Re-
ceived September 24, 1985; revision requested
November 6, 1985; revision accepted February
3, 1986. From the 1985 RSNA annual meeting.
a.
Address reprint requests to G.J.K. Supported
by the Dutch Cancer Foundation, Integrated Figure 1. Axial scout MR images (5 mm-thick section; TR 250 msec, TE 30 msec). (a)
Cancer Center West Grant 8589. The line AB indicates the imaging plane parallel to the glenoid cavity. (b) The line AB mdi-
© RSNA, 1986 cates the longitudinal imaging plane perpendicular to the glenoid cavity.

741
 15t

23

b. c.

d. e. f.

h. i.
Figure 2. Oblique views, parallel to the plane of the glenoid cavity (line AB in Fig. la). a, d, and g are MR images (5 mm-thick section; TR
250 msec, TE 30 msec); b, e, and h are corresponding sections of a cadaver specimen in the same plane; c, f, and i are anatomic drawings
corresponding to the MR images and cadaver specimens. (a-c) Section through the lateral part of the humeral head. The rotator cuff tendons
(14t, 15t) are clearly visible as is the tendon of the long head of the biceps (23t). The hyaline articular cartilage of the humeral head is seen as
an area of high signal intensity. (d-f) Section through the glenoid cavity and the coracoid process. The supraspinatus (14) and infraspinatus
(15) muscles are cut as is the subscapularis (16) muscle. Notice the relation of the subscapulanis muscle and the neurovascular bundle (*).

(g-i) Section through the medial border of the scapula. The bellies of the rotator cuff muscles (14-16) are cut near their origin.

Key to Figure legends 2-5: liii humerus (marrow), Ic humerus (cortex), 2 humeral head, 3 glenoid, 4 neck of the scapula, 5
spine of the scapula. 6 lateral border of the scapula, 7 inferior angle of the scapula, 8 coracoid process, 9 acromion, 10 clavicle, 11
= acromioclavicular joint, 12 trapezius, 13 deltoid, 14 supraspinatus muscle, 14t = supraspinatous tendon, 15 mnfraspmnatus muscle,
151 = infraspinatous tendon, 16 = subscapularis muscle, 16t subscapulanis tendon, 17 pectoralis major, 18 pectoralis minor, 19 = teres
major, 20 = teres minor, 21 latissimus dorsi, 22 intercostal muscle, 23b biceps muscle (short head), 23t biceps (tendon of the long
head), 24 = coracobrachialis, 25 lung, 26 subscapular bursa, * neurovascular bundle, gi glenoid labrum.

742 . Radiology June 1986

 ‘3 00’

7 . . ...

b. c.

14t

:.
: I
e. f.

ic
cii
h. 1.

Figure 3. Oblique views, parallel and longitudinally perpendicular to the glenoid cavity (line AB in Fig. lb). a, b, and g are MR images (5-
mm-thick section; TR = 250 msec, TE = 30 msec); b, e, and h are corresponding sections of a cadaver specimen in the same plane; c, f, and i are
anatomic drawings corresponding to the MR images and cadaver specimens. (a-c) Section through the clavicle and coracoid process, anterior
to the humeral head. The tendinous insertion of the subscapulanis muscle is cut (16t). The fasciculi of the muscle can be identified by a high
intensity signal because of the fat that surrounds the bundles. (d-f) Section through the humeral head and scapula. The hyaline articular car-
tilage of both the glenoid cavity (+) and humenal head has a high signal intensity, in contrast with the fibrous cartilage of the glenoid la-
brum (gi). Notice the supraspinatus muscle (14), which is cut in its entire length from origin to insertion (14t). (g-i) Section through the acro-
mion and dorsal part of the humerus. Cortical bone (Ic) in the humeral head and shaft has a low signal intensity. Therefore, the
supraspinatus tendon (14t), which also has a low signal intensity, cannot be distinguished in this area. Note the epiphyseal line in the hu-
meral head region.

images (matrix, 256 X 256; resolution, ±1 on axial scout views; the angle usually The repetition time (IR) was determined
mm) were obtained in axial, sagittal, con- ranged between 25#{176}
and 35#{176}(Fig. la, ib). by the number of sections and was
onal, and two oblique planes. Each The two oblique planes were further 250-500 msec with echo times (TE) of 30
oblique plane was longitudinally pempen- evaluated in both shoulders of one cadav- msec and 1,000-1,500 msec with TE of 50
diculan on parallel to the surface of the en. After MR imaging, the specimens msec.
glenoid cavity, with the humerus in the were cryosectioned (6-mm-thick sections)
neutral position (Fig. la, lb). The angle in the two corresponding planes.
widths of the oblique planes were plotted A spin echo (SE) technique was used.

Volume 159 Number 3 Radiology 743

#{149}
 RESULTS 26

Signal Intensity

Bone marrow, with its relatively

long T2 and short Ti relaxation
times, has a high signal intensity on
Ti- and T2-weighted images. Bone
marrow of the humerus, glenoid
area, acromion, coracoid process,
clavicle, and scapula can easily be
identified (Figs. 2a, 2d, 2g; 3a, 3d, 3g).
Cortical bone, on the other hand,
shows a low intensity line (indepen-
dent of the pulse sequence used) as a
4b.
result of the low spin density and
short T2 relaxation time of compact
bone (Fig. 3g).
The articular surfaces of the glen- 4a.
oid cavity and the humeral head are
covered with hyalmne cartilage, 1
which has a high signal intensity on
both Ti- and T2-weighted images
(Figs. 3d, 4a). Fibmocartilage of the
glenoid labrum and the articular sum-
faces of the acromioclavicular joint is
demonstrated by moderately low sig-
nal intensity on Ti- and T2-weighted S
images (Fig. 3d). The rotator cuff ten-
dons have low signal intensity which
is not easily distinguished from that
of the cortical bone of the greater tu-
berosity and humeral head (Figs. 2a,
3g).
Subcutaneous fat and fat between
the separate muscles has high signal
intensity. Muscle fibers converging
into tendon can be indirectly ob- 5a. 5b.
served because of the high signal in- Figures 4, 5. (4) Axial view through the lower part of the shoulder. (a) MR image (5-mm-
tensity of fat surrounding the ten- thick section; TR = 500 msec, TE 30 msec). (b) Anatomic drawing. Hyalmne articular cart!-
dons (Fig. 3a). lage as well as the subscapular bursa (26) can be seen between humeral head (2) and glenoid
(3). Note the neurovascular bundle (*). (5) Parasagittal view through the m!dscapu!a. (a) MR
image (5-mm-thick section; TR 250 msec, TE 30 msec). (b) Anatomic drawing. The neur-
Multiplanar Display of Normal ovascular bundle (8) is seen traversing the axillary fat; its relation to the surrounding mus-
Anatomy des i5 shown.

Axial plane-The relation between

the humemal head and the glenoid
cavity is demonstrated in the axial the sagittal plane when the phase-en- ally varies between 25#{176}
and 35#{176}. The
plane and is similar to that seen us- coding gradient is in the anterior- plane of choice in each patient is that
ing computed tomography (CT). MR posterior direction. The coronal plane exactly parallel to the glenoid
images demonstrate hyaline cartilage plane is well-suited for imaging of cavity. Variations in the position of
and the labrum (Fig. 4a). the acromioclavicular joint and its me- the patient do not affect the repro-
The tendon of the long head of the lation to the supraspinatus muscle. ducibility of this method of plane se-
biceps is easily identified. The del- A disadvantage of the sagittal and lection (Fig. la).
toid muscle, muscle groups anterior coronal planes is the variation among Glenoid and coracoid processes are
and posterior to the scapula, several patients of the relationship of these clearly depicted in this view. The
intramuscular and intemmusculam sep- planes to the shoulder anatomy. This muscles of the rotator cuff and the
ta and compartments, and the axil- relationship varies as a result of van- teres major muscle are all well visual-
lary neumovascular bundle can be ap- ation in the positions of the scapula. ized (Fig. 2a, 2d, 2g).
preciated as separate structures (Fig. For this reason, and to display Oblique plane, longitudinally perpcn-
4a). obliquely oriented structures better, dicular to f/ic glenoid cavity-Selection
Sagittal and coronal planes-The me- two oblique planes (parallel to and of the plane of choice is again facili-
lationship between the neumovascu- longitudinally perpendicular to the tated using a transverse scout view as
lam bundle (as it traverses the axillary glenoid cavity) were evaluated. a reference (Fig. ib). The rotator cuff
fat) and the thoracic wall and subsca- Oblique plane, parallel to f/ic glenoid muscles, especially the supraspinatus
pulam and pectoral muscles is best cavity-This plane is selected on a muscle (which lies exactly in this
shown in the sagittal plane (Fig. 5a). transverse scout view. The angle be- longitudinal plane), are very well
Respiratory movements do not inter- tween the plane parallel to the glen- demonstrated (Fig. 3d). Other struc-
feme with the acquisition of data in oid cavity and the coronal plane usu- tures-such as the glenohumeral and

744 Radiology
#{149} June 1986
acromioclavicular joints, the coracoid limited value. The sagittal plane is, 9. Goldman AB, Ghelman B. The double
process, and the subscapulanis mus- however, very well-suited for dis- contrast shoulder arthrogram: a review of
158 studies. Radiology 1978; 127:655-663.
cle-can be evaluated in detail. playing the neurovascular bundle
10. Neviaser TJ. Arthrography of the shoul-
and its relation to surrounding struc- der. Orthop Clin North Am 1980;
tunes. This plane can also be impon- 11:205-217.
DISCUSSION 1 1. El-Khoury GY, Albright JP, Abu Yousef
tant in staging bone tumors (17).
MM, Montgomery WJ, Tuck SL. Arthro-
MR offers the opportunity to study It may be feasible to develop sun-
tomography of the glenoid labrum. Radi-
normal anatomy in multiple planes face coils for imaging different pants ology 1979; 131:333-337.
with high contrast and high spatial of the shoulder (e.g., the acromiocla- 12. Deutsch AL, Resnick D, Mink JH, et al.
resolution. This can be achieved in vicular joint) in order to increase the Computed and conventional arthrotomog-
raphy of the glenohumera! joint: normal
the shoulder region by using a sun- spatial resolution even further. MR
anatomy and clinical experience. Radiolo-
face coil of specific design (15, 16). imaging with anatomically shaped
gy 1984; 153:603-609.
The selection of imaging planes is surface coils is a technical improve- 13. Haynor DR, Shuman WP. Double con-
important in imaging both normal ment which, if used in conjunction trast CT arthrography of the glenoid Ia-
with the oblique planes described brum and shoulder girdle. Radiographics
anatomy and pathologic conditions.
1984; 4:411-421.
By selecting appropriate imaging here, can augment the use of MR in
14. Stnizak AM, Danzig L, Jackson DW, Res-
planes, optimal information can be evaluating shoulder anatomy. U nick D, Staple T. Subacromial bursog-
obtained while keeping the imaging raphy. J Bone Joint Surg 1982;
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Magn Reson Med (in press).
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Volume 159 Number 3 Radiology 745

#{149}