Skeletal Radiol (2002) 31:373–383

DOI 10.1007/s00256-002-0528-6 R E V I E W A RT I C L E

K. W. Carroll Magnetic resonance imaging

C. A. Helms
of the shoulder: a review of potential sources
of diagnostic errors

Received: 24 July 2001
Revised: 7 December 2001
Accepted: 12 April 2002
Published online: 1 June 2002
© ISS 2002
K.W. Carroll (✉)
Radiology Regional Center,
700 Goodlette Rd. N, Naples,
FL 34102, USA
e-mail: KCNDRAD@aol.com
Tel.: +1-919-6847272
Fax: +1-919-6847138
C.A. Helms
Duke University Medical Center,
Department of Radiology, Box 3808,
Durham, NC 27710, USA
Abstract Shoulder magnetic reso-
nance (MR) imaging and MR ar-
thrography are frequently utilized in
the evaluation of shoulder pain and
instability. The clinical scenario and
imaging findings may be confusing
to clinicians and radiologists and
may present diagnostic challenges
for those involved in evaluating and
treating shoulder pathology. Often
rotator cuff and labral abnormalities
may be coexistent, clinical manifes-
tations of denervation syndromes
may be confusing to clinicians, and
normal anatomic variations, imaging
pitfalls, and various artifacts may
cause dilemmas for the radiologist.
This article will review the most
frequently encountered mimickers
and pitfalls of MR imaging of the
shoulder.
Keywords Shoulder, MR ·
Shoulder, arthrography · Magnetic
resonance (MR), arthrography

Introduction Imaging pitfalls

Magnetic resonance (MR) imaging and MR arthrography
have become the main diagnostic imaging procedures for
the evaluation of clinical shoulder disability. Patients may
come to imaging with very confusing signs and symp-
toms, and the entire shoulder should be evaluated thor-
oughly in order to arrive at the correct diagnosis and
render appropriate therapy. The patient’s age, clinical his-
tory, surgical history, and physical examination findings
may point to various diagnoses such as rotator cuff or la-
bral abnormalities. However, these structures may have
coexistent pathology as one may lead to or arise from the
other. Several articles have addressed pitfalls [1, 2], nor-
mal anatomic variations [1, 2, 3, 4, 5, 6, 7, 8, 9], artifacts
[10], and various denervation abnormalities about the
shoulder [11, 12, 13, 14, 15], which may perplex both the
shoulder imager and the clinician examining the patient.
This review addresses the imaging and clinical mimickers
and pitfalls seen at MR imaging of the shoulder in order
to improve the diagnostic accuracy and confidence of ev-
eryone involved in the evaluation of the shoulder.
Several artifacts that involve the acquisition of images
during MR imaging and MR arthrography may be misin-
terpreted as pathology and result in diagnostic errors.
When evaluating the images, the technique and patient
position used to obtain the image must also be evaluated.
Internal rotation
The shoulder should be neutral or preferably externally
rotated while the patient is supine in the magnet. If the
shoulder is internally rotated (Fig. 1), this may cause ap-
parent abnormal signal in the supraspinatus caused by
narrowing of the interval between the supraspinatus and
infraspinatus [16]. This causes apparent focal increased
signal in the supraspinatus tendon, which may be mistak-
en for a cuff abnormality (Fig. 2). In addition, internal
rotation may cause apparent redundancy of the anterior
structures, making evaluation of the anterior labrum and
subscapularis less than optimal. The amount of internal
374
Fig. 1 Effect of internal rotation. Shoulder in the axial plane,
showing the effect of internal rotation on the interval between the
supraspinatus tendon and the infraspinatus tendon
Fig. 2A,B MR appearance of internal rotation. Oblique coronal
fast spin-echo T2-weighted image with fat suppression (TR/TEeff,
3500/67) images through the anterior shoulder show this effect of
internal rotation causing apparent increased signal in the supraspi-
natus tendon. A Neutral/external rotation reveals normal low sig-
nal (arrow) in the supraspinatus tendon. B Internal rotation pro-
duces apparent tendinopathy in the supraspinatus (curved arrow),
which is actually the interval between the supraspinatus and infra-
spinatus
or external rotation is best evaluated on the axial images
by looking at the relationship of the bicipital groove to
the anterior glenoid (Fig. 3).
Magic angle
The MR imaging artifact of the magic angle phenome-
non has been well described [17, 18, 19]. The tendon ori-
entation in relation to the static magnetic field (B0) may
result in spurious increased signal in the critical zone of
the supraspinatus tendon and may lead to a misdiagnosis
of tendinopathy or partial tear. Hyperintense signal may
be seen within tendons when the tendons are aligned at
the “magic angle” of 55° in relation to the constant mag-
netic induction field (B0) on short TE images. This is es-
pecially a dilemma with the supraspinatus tendon in MR
imaging of the shoulder. The observer should use the
second echo of conventional spin-echo long TR images
to look for normal hypointense signal and recognize this
effect to avoid diagnostic inaccuracy. This has become
less problematic as fewer imagers rely on the oblique co-
ronal T1-weighted images and conventional spin-echo
proton-density images for rotator cuff pathology.
Poor fat suppression
If there is nonuniform fat suppression, then fat-contain-
ing structures such as marrow and subcutaneous fat may
yield spurious abnormal high signal on fast spin-echo
T2-weighted images. This may be evaluated on other im-
ages and, if necessary, may be corrected by adding an in-
version recovery sequence in the same imaging plane.
Metal, which may be found in the postoperative shoul-
der, can interfere with fat suppression by altering the
field homogeneity; inversion recovery sequences should
therefore be considered in postoperative patients.
Overdistention
MR arthrography is an excellent imaging technique for
evaluating the labrum and glenohumeral ligaments in the
setting of suspected glenohumeral instability [6, 20, 21].
However, the arthrographic technique may introduce
several potential pitfalls in evaluating the shoulder.
Overdistention of the joint capsule was confused early in
the MR arthrography experience as a type III capsule [2]
or capsular stripping. In addition, overdistention may
lead to extravasation of contrast, which may suggest a
pathologic capsular injury.
Air injection
If there has been inadvertent injection of air during the
arthrogram, a rounded signal void may be mistaken ei-

Fig. 3A–C Evaluation of extent of external or internal rotation.
A Axial drawing of the expected location of the bicipital groove
(arrow) in external rotation. A straight line is drawn in the sagittal
plane through the humeral head. The groove seen medial to this
line (left) is the position of the bicipital groove when the shoulder
is internally rotated. The amount of internal or external rotation
may be assessed by the position of the bicipital groove. B Axial
fast spin-echo proton density-weighted images (TR/TEeff,
2000/32) in neutral/external rotation reveal the bicipital groove
(arrow) in a more lateral position (left). C When the shoulder is in
internal rotation, the groove (curved arrow) is seen in a more me-
dial location (right)
375
Fig. 4A,B Inadvertent air injection on MR arthrogram. A Axial
T1-weighted (TR/TE, 500/11), fat-suppressed post-arthrogram im-
age revealing a small, low-signal focus structure (arrow) just pos-
terior and lateral to the coracoid process (curved arrow). B On ax-
ial multiplanar gradient recall sequence (MPGR) T2-weighted
(TR/TE/flip angle = 500/15/35) image, this injected air (arrow)
appears darker and larger secondary to “blooming” from magnetic
susceptibility artifact, which is more pronounced with gradient-
echo imaging
ther for a loose body or a labral tear (Fig. 4). If gradient
echo images are obtained, there will be marked “bloom-
ing” artifact, causing the air bubble to look larger and
darker on these images. Care should be taken to try to
avoid injecting air if possible. There is no significant po-
tential complication for the patient, unless surgery is per-
formed to remove the “loose body” that was inadvertent-
ly injected.
Subcoracoid bursa injection
If the contrast is not injected into the glenohumeral joint,
the study will lack the distention needed to identify the
glenohumeral ligaments and accurately evaluate for in-
376

Fig. 5 Subcoracoid bursa injection on MR arthrography. An

oblique sagittal T1-weighted (TR/TE, 550/19), fat-suppressed,
post-arthrogram image showing that the majority of the dilute ga-
dolinium has been unintentionally injected in the subcoracoid bur-
sa (arrow). A small amount of contrast was injected into the sub-
scapularis recess (curved arrow) of the glenohumeral joint (which
is deep to the subcoracoid bursa) from an anterior approach

stability. In addition, if the contrast is injected into the

subcoracoid bursa, there may be potential confusion for
a rotator cuff tear, as the dilute gadolinium may commu-
nicate normally with the subacromial bursa [5]. Inadver-
tent injection into the subcoracoid bursa typically occurs
when the needle tip is not placed deeply enough. The
subcoracoid bursa is easily recognized by its location an-
terior to the subscapularis muscle (Fig. 5). It does not
communicate with the glenohumeral joint, but communi-
cates with the subacromial bursa in up to 20% of cases
[5].

Normal anatomic variants

Sublabral foramen

Several normal anatomic variants of the anterosuperior

labrum have been described [22, 23]. The most common
of these is the sublabral foramen or sublabral hole [6, 7,
8, 9]. This is a normal opening between the superior and
middle glenohumeral ligaments (Fig. 6), but may look
like a detached or torn labrum at MR imaging and MR
arthrography. This normal variant should not be misdiag-
Fig. 6A–C Sublabral foramen. A Right glenoid from a lateral
view with a superimposed clockface showing the typical location
and extent of a normal variant sublabral foramen in the anterior
superior quadrant. BT, biceps tendon; SGHL, superior glenohu-
meral ligament; MGHL, middle glenohumeral ligament; AB, ante-
rior band of the inferior glenohumeral ligament; ant, anterior;
post, posterior. The shaded area from 1:00 to 3:00 corresponds to
the anatomic location of a sublabral foramen. T1-weighted
(TR/TE, 500/16), fat-suppressed, post-arthrogram images portray
the appearance at MR arthrography, which may be confused with
a labral tear. B Oblique sagittal image with anterior to the right
(correlates with Fig. 6a), showing dilute gadolinium extending in-
to an opening (arrow) in the labrum, which was proved to be a
sublabral foramen at arthroscopy. C Axial image from the same
patient, also showing the smooth defect (curved arrow) in the an-
terior superior labrum

Fig. 7 Buford complex. Axial T1-weighted (TR/TE, 600/20),
post-arthrogram image showing the normal variant without the an-
terior superior labrum (arrow) and a thickened, cord-like middle
glenohumeral ligament (curved arrow), which constitutes the
Buford complex that was confirmed at arthroscopy in this patient
nosed as a Bankart lesion [24]. The opening should be
confined to the anterosuperior quadrant of the labrum
(1:00 to 3:00 if looking at a clockface representation of a
lateral view of the right shoulder). If the abnormality ex-
tends more posteriorly (towards 11:00), then a superior
labrum anterior to posterior (SLAP) lesion [25] should
be considered. If the signal continues inferiorly (towards
4:00), then a Bankart-type injury should be entertained.
Moreover, the sublabral foramen should have relatively
smooth borders and should not have additional findings
of glenohumeral instability. A sublabral foramen is a
common normal variant, seen in 11% of normal shoul-
ders [26], whereas a labral detachment isolated to the an-
terosuperior labrum is rare [2].
Buford complex
The Buford complex has been frequently referenced in
the recent literature [2, 3, 6, 7, 8, 21, 27, 28]. This nor-
mal anatomic variant consists of an absent anterior supe-
rior labrum and thickened, cord-like middle glenohumer-
al ligament (MGHL). The thickened MGHL may have
the appearance of a detached anterior labral tear or a dis-
located biceps tendon at MR imaging and MR arthrogra-
phy (Fig. 7). This normal variant is somewhat uncom-
mon, with a reported occurrence of 1.5% [8].
Sublabral recess
The sublabral recess [4, 9, 27], which should not be mis-
taken for a sublabral foramen, may cause frustration for
those trying to evaluate for SLAP lesions. In cadavers, a
377
recess as deep as 2 mm has been reported to be as com-
mon as 39% [4]. This normal anatomic variant consists
of a meniscoid attachment of the superior labrum to the
glenoid. The sublabral recess occurs from 11:00 to 1:00
on the clockface, as opposed to the sublabral foramen,
which is located more anteriorly from 1:00 to 3:00. Sev-
eral findings should help the imager distinguish this
from a SLAP. The normal sublabral recess should not
continue posterior to the biceps anchor, should not have
abnormal signal extending laterally into the intra-articu-
lar portion of the tendon for the long head of the biceps,
and should not be irregular in morphology. If any of
these findings are present, then a SLAP lesion should be
considered [29] rather than a sublabral recess (Fig. 8).
Absent middle glenohumeral ligament
Of all the glenohumeral ligaments, the MGHL is the
least constant [2]. It may be thin, thick, or absent on MR
imaging or MR arthrography. Knowing the variable na-
ture of this ligament should help in avoiding diagnostic
errors.
Os acromiale
One of the osseous normal variants about the shoulder is
failure of fusion of the acromion. After skeletal maturity,
the scapula should be completely fused. Fusion should
be complete by age 25. However, the acromion process
of the acromion may fail to fuse, resulting in an os acro-
miale [30]. This may be difficult to visualize at MR im-
aging [31], but this accessory ossicle may have implica-
tions in surgical outcomes [32, 33, 34, 35]. The deltoid
attaches to the acromion and, if an os acromiale is pres-
ent, can cause impingement by pulling the unfused por-
tion of the acromion downward into the supraspinatus
tendon. It is imperative to recognize this on MR imaging
[36], as it can be difficult to appreciate at arthroscopy.
Failure to fixate an os acromiale is felt by some to be a
source of failed shoulder surgery [37]. The os acromiale
is best visualized on the axial images (Fig. 9). The tech-
nologist should make sure that the most superior axial
images begin cephalad to this area, as it may be more
difficult to see in other planes.
Duplicated tendon for long head of biceps
An anatomic variant about the shoulder is a third or
fourth head of the biceps brachii muscle, which has been
reported to occur in as many as 10% of people [38]. This
may look like a longitudinal split tear at MR imaging
(Fig. 10) if the anomalous muscle has a tendon slip run-
ning with the tendon of the long head of the biceps in the
378
Fig. 8A–C Sublabral recess. The meniscoid attachment of the su-
perior labrum or sublabral recess is different from the sublabral fo-
ramen and should be distinguished from a superior labrum anterior
to posterior (SLAP) lesion. A Location of the sublabral recess in
the shaded area from 11:00 to 1:00 on the clockface. BT, biceps
Fig. 9 Os acromiale. The acromion process of the scapula should
be fused by age 25 at skeletal maturity. Axial T1-weighted
(TR/TE, 550/11), fat-suppressed, post-arthrogram image showing
the normal variant os acromiale (arrow). If the orthopedic surgeon
is unaware of this variant, the deltoid may pull on this unfused
portion of the acromion, leading to impingement and failed shoul-
der surgery
bicipital groove in a common tendon sheath. Clinical
correlation with symptoms of biceps tendinopathy may
be necessary to make this distinction. At imaging, asso-
ciated biceps pathology findings such as fluid in the ten-
don sheath may also be looked for.
Denervation abnormalities
Several denervation abnormalities may be seen in the
musculature within the shoulder girdle [39, 40, 41, 42,
43, 44]. Patients may present with rotator cuff weakness
or glenohumeral instability, thus presenting a diagnostic
dilemma to the referring clinician [45]. Often entrapment
of nerves may be related to ganglia associated with la-
bral tears. Acute denervation changes are best visualized
as increased signal within the muscle bellies on fat-sup-
pressed, fast spin-echo T2-weighted images or inversion
recovery images. The abnormal signal in the rotator cuff
musculature is best evaluated on the oblique sagittal im-
tendon; SGHL, superior glenohumeral ligament; MGHL, middle
glenohumeral ligament; AB, anterior band of the inferior glenohu-
meral ligament. B The sublabral recess on this oblique coronal,
T1-weighted (TR/TE, 600/15), fat-suppressed, post-arthrogram
image has a smooth appearance (arrow) and does not extend pos-
terior to the biceps anchor (open arrow). C The oblique coronal,
T1-weighted (TR/TE, 650/17), fat-suppressed, post-arthrogram
image shows a SLAP lesion with dilute gadolinium extending into
an irregular superior labrum (curved arrow) that also extended
posterior to the biceps anchor on subsequent images
 379

ages. More chronic changes of atrophy are best appreci-

ated as hyperintense fat signal and small muscle size on
T1-weighted images without fat suppression.

Suprascapular nerve entrapment

The suprascapular nerve runs within the spinoglenoid

Fig. 10 Duplicated tendon for the long head of the biceps. Axial
multiplanar gradient recall sequence (MPGR) T2-weighted
(TR/TE/flip angle, 500/15/35) image demonstrating a duplicated
tendon with two slips in the bicipital groove (short arrows). There
is evidence of bursitis with fluid in the subcoracoid (arrow) and
the subdeltoid (curved arrow) bursae, but there is no fluid in the
biceps tendon sheath
notch and suprascapular notch of the scapula. It inner-
vates the suprapinatus and infraspinatus muscles of the
rotator cuff. The nerve is most commonly compressed by
ganglia from paralabral cysts [46, 47, 48, 49], which are
usually associated with labral tears (Fig. 11). If the cyst
compresses the nerve more posteriorly, the infraspinatus
is affected primarily. As the cyst becomes larger or if is
located more anteriorly, then it may also affect the inner-
vation of the supraspinatus. Other masses including sar-
comas and hematomas have been reported within the re-
gion of the suprascapular nerve [46], also giving rise to
compression neuropathy. Varices or vasular malforma-
tions within the spinoglenoid notch may also compress
the nerve [12]. These masses are best visualized
on the oblique sagittal fat-suppressed, fast spin-echo,

Fig. 11A–D Suprascapular

nerve entrapment from
paralabral ganglion cyst.
A Oblique sagittal fast spin-
echo T2-weighted image with
fat suppression (TR/TEeff,
5016/114) with anterior to the
right demonstrating a fluid
signal ganglion (arrow) in the
spinoglenoid notch with dener-
vation changes of increased
signal in the infraspinatus mus-
cle (curved arrow). B The large
cyst is seen on this oblique co-
ronal fast spin-echo T2-weighted
image with fat suppression
(TR/TEeff, 3000/114) extending
medially (arrow) along the
scapula (curved arrow).
C Oblique coronal, T1-weighted
(TR/TE, 466/10) fat-sup-
pressed, post-arthrogram image
from the same patient confirm-
ing communication with the
glenohumeral joint, with dilute
gadolinium (arrow) extending
into the cyst through a postero-
superior labral tear (curved
arrow). D The tear is slightly
more conspicuous on the axial
T1-weighted (TR/TE, 350/10),
fat-suppressed, post-arthrogram
image, with gadolinium (curved
arrow) going through the tear
into the ganglion (arrow) in
the spinoglenoid notch (short
arrow)
380

Fig. 12 Quadrilateral space. Posterior view showing the axillary

nerve (black lines), which may be compressed in the quadrilateral
space formed by the teres major, teres minor, and triceps muscles
as well as the humerus

T2-weighted images. The intra-articular communication

of paralabral cysts through labral tears is best seen on
MR arthrography.

Quadrilateral space syndrome

The axillary nerve may be compressed as it passes

through the quadrilateral space (Fig. 12), resulting in
weakness and atrophy of the teres minor and deltoid
muscles. Quadrilateral space syndrome [11, 50, 52] is
most frequently the result of scar with fibrous bands con-
stricting the axillary nerve. However, any mass in this re-
gion may have a similar effect, including a paralabral
cyst [53]. The patient may present with apparent rotator
cuff tear or deltoid injury. The muscles themselves
should be carefully inspected for atrophy, especially on Fig. 13A,B Quadrilateral space syndrome. Oblique sagittal imag-
es showing the cause and effect of the quadrilateral space syn-
the oblique sagittal images (Fig. 13). drome. A T1-weighted (TR/TE, 500/16) image revealing high sig-
nal consistent with fatty atrophy of the teres minor muscle (ar-
row). A rounded, low-signal focus (curved arrow) could be mis-
Parsonage-Turner syndrome (acute brachial neuritis) taken for muscle. B However, on the fast spin-echo T2-weighted
image with fat suppression (TR/TEeff, 4000/68), this proved to be
a fluid signal paralabral ganglion cyst (arrow) arising from a la-
Parsonage-Turner syndrome was first described long be- bral tear (not shown)
fore the advent of MR imaging [15]. Recently, the MR
imaging findings have been described [12, 13]. The eti-
ology of this neuritis is still unknown, but it presents ing pain and weakness, as opposed to the more insidious
clinically as pain and weakness [54, 55, 56] and may be onset of symptoms in nerve entrapment entities. It may
mistaken for a rotator cuff tear, brachial plexus injury, or be bilateral in up to 15% of patients [13].
cervical spine abnormality. This syndrome is seen as
denervation changes on MR imaging similar to the com-
pressive neuropathies, yet there is no mass present Clinical evaluation
(Fig. 14). The imager should evaluate the signal within
the muscles of the shoulder girdle and search for masses Coexistent cuff and labrum pathology
as well as cuff and labral pathology. If the only abnor-
mality is the muscle, then this self-limited syndrome It is very convenient to try to isolate rotator cuff disease
may be present. The symptoms may last up to 1 year, but from glenohumeral instability or labral pathology. How-
should resolve without surgical intervention. These pa- ever, these two apparently disparate categories of shoul-
tients classically present with sudden onset of debilitat- der disease often coexist [57, 58, 59]. The rotator cuff is

Fig. 14A,B Parsonage-Turner syndrome. Acute brachial neuritis or
Parsonage-Turner syndrome should be suspected when there are
findings of a compressive neuropathy without a mass. Oblique sag-
ittal images with anterior to the left showing the MR findings. A On
the T1-weighted (TR/TE, 600/20) image, there is evidence of atro-
phy and fat in the supraspinatus (curved arrow) and infraspinatus
(arrow) muscles. B On the fast spin-echo T2-weighted image with
fat suppression (TR/TEeff, 5000/64), there is increased signal consis-
tent with denervation changes in the supraspinatus (curved arrow)
and infraspinatus (arrow) muscles. This self-limited entity may last
up to 1 year, but should resolve without surgical intervention
responsible for active stability of the glenohumeral joint,
and the labral–ligamentous complex provides passive
stability. As such, disease in one area often produces pa-
thology in the other and vice versa. It is important for the
clinician and imager to keep this fact in mind when eval-
uating patients with shoulder pain.
Fluid in the subacromial bursa
When evaluating the rotator cuff, the finding of fluid in the
subacromial bursa is one of several findings at MR imag-
381
Fig. 15 Dislocated biceps tendon. An axial, fat-suppressed, proton
density (TR/TE, 2000/20) image reveals a rounded, low-signal fo-
cus (arrow) adjacent to the anterior labrum, which could be mis-
taken for a labral tear or loose body. However, the dislocated bi-
ceps tendon may be diagnosed by recognizing that the bicipital
groove (short arrow) is empty. In addition, the anterior labrum
(curved arrow) has normal morphology, and there is abnormal
high signal in the subscapularis (long arrow), which has been in-
jured
ing that suggests rotator cuff pathology and possible tear.
Several causes of fluid in the subacromial bursa have been
described which may mimic rotator cuff pathology, and
the imager should be aware of these. Fluid from a recent
therapeutic injection into the subacromial bursa [10] often
persists for up to 48 h but may last as long as a week. If
the patient has had a recent therapeutic injection, this
should be documented on the patient questionnaire. Ideal-
ly, MR imaging should be delayed if possible for up to a
week to avoid potential diagnostic confusion. If this is not
possible, then the injection should be kept in mind when
evaluating images. Fluid may also be seen at MR imaging
in the subacromial bursa without a rotator cuff tear sec-
ondary to isolated subacromial or subcoracoid bursitis. As
previously mentioned, the subcoracoid bursa may commu-
nicate with the subacromial bursa in up to 20% of cases.
Dislocated biceps tendon confused
for anterior labral tear
When the tendon for the long head of the biceps dislo-
cates, it often does so posteriorly and medially and may
be seen adjacent to the anterior aspect of the labrum.
This may be mistaken for a detached anterior labral tear
or a Buford complex (Fig. 15). Care should be taken to
evaluate the bicipital groove for the normal presence of
the tendon to avoid this misdiagnosis. In addition, this
injury is often associated with injuries to the subscapu-
laris tendon with disruption of the transverse humeral
382

ligament that holds the biceps in place. Careful inspec-
tion of these structures should also be performed.
Conclusion
The shoulder is a complex joint, and there are myriad
potential pitfalls in assessing and treating shoulder dis-
ease. The clinical and imaging evaluation may be fraught
with confusion for the clinician and radiologist alike. We
have tried to summarize some of the more common po-
tential sources of diagnostic errors encountered during
MR imaging of the shoulder. This should increase the ac-
curacy and confidence of those involved in the imaging
of shoulder pathology and help avoid unnecessary sur-
gery.

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