The shoulder

 most sophisticated and complicated joints of the body

 It has the greatest range of motion than any joint in the body
 the shoulder is 'unstable' compared to other joints of the body
Joints (shoulder complex)
 Parts of Synovial Joint
• Articulating bones
• Synovial membrane
• Fibrous capsule
• Intra-articular structures (like labrum)
• Ligaments
• Bursae
• Muscles
 Glenohumeral Joint
– Ball and socket synovial joint
– Very mobile
– instability
– 45% of all dislocations !!
– Joint stability depends on multiple factors (static
and dynamic stabilizers)
 Functional Anatomy
• Glenohumeral joint is a ball and socket synovial.
• Glenoid cavity inherently unstable.
• Stability provided by:
– Static constraints
 3 glenohumeral ligaments
 glenoid labrum
 joint capsule
– Dynamic constraints
• Predominantly rotator cuff muscles and biceps (long head)
• Also scapular stabilizers : Trapezius, levator scapulae,
serratus anterior, rhomboids
Bones
 Glenoid labrum
• Fibrocartilage similar to knee menisci
• Deepens the glenoid fossa
Ligaments
Muscles
 Bursae
• Sac between two moving surfaces that
contains a small amount of lubricating fluid
• To reduce friction
 Acromioclavicular joint

• Diarthrodial joint / Gliding synovial joint

• Thin capsule
• AC ligaments
– Anterior, posterior, superior, inferior
• Coracoacromial ligament
• Coracoclavicular ligaments
– Trapeziod ligament
– Conoid ligament
 Radiography
• Initial investigation of choice for all shoulder problems.

• Can detect most fractures, dislocations, calcific tendinitis and

other skeletal causes of pain such as arthritis and bone tumors

• Different situations require different types of plain films

(AP/Lateral/Axillary views):
– Impingement views in clinically suspected impingement
syndrome and/or rotator cuff tears to detect subacromial
spur
– Axial or anterior oblique views in trauma
 AP :
Routine view

• AP relative to thorax
• Suboptimal view of
Glenohumeral joint
• Good view of AC
joint
 Axillary lateral View

Good view of anterior-posterior relationship of GH joint

Shoulder X-ray, AP projection

1. Clavicle
2. Acromion
3. Greater tubercle
4. Lesser tubercle
5. Neck of Humerus
6. Humerus
7. Coracoid Process
8. Axillary border of scapula
9. Rib

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 CT
• Superior to plain radiographs in evaluation of complex
fractures and fracture-dislocations involving the head of the
humerus
• Allows planning of treatment of complex proximal humeral
fractures
 CT
1) Glenoid 9) Teres minor
2) Humerus 10) Triceps
3) Deltoid 11) Pec major
4) Infraspinatus 12) Pec minor
5) Scapula 13) Biceps (long)
6) Supraspinatus 14) Biceps (short)
7) Clavicle 15) Teres major
8) Subscapularis 16) Latissimus
 MRI
• Highly accurate for evaluation of rotator cuff pathologies
• Indicated when further investigation of rotator cuff pathology is
needed.
• Comprehensive display of soft tissue anatomy
– Demonstration of the causes for impingement
– Useful in characterization and staging of bone tumors
 Rotator Cuff (Coronal)

-Primary Plane for Evaluating -Musculotendinous Junction at

the Supraspinatus Tendon 12:00 Position
MRI of the shoulder. Sagittal T2 FATSAT. Image 1

1. Subscapularis muscle
2. Supraspinatus muscle
3. Trapezius muscle
4. Deltoid muscle
5. Infraspinatus muscle
6. Scapula
7. Teres minor muscle
8. Triceps muscle

25
MRI of the shoulder. Sagittal T2

1. Subscapularis muscle
2. Clavicle
3. Trapezius muscle
4. Supraspinatus muscle
5. Infraspinatus muscle
6. Scapula
7. Teres minor muscle
8. Deltoid muscle

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MRI of the shoulder.

1. Subscapularis muscle
2. Coracoid process
3. Clavicle
4. Trapezius muscle
5. Supraspinatus muscle
6. Acromion
7. Infraspinatus muscle
8. Scapula
9. Teres minor muscle
10. Deltoid muscle
11. Triceps muscle

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MRI of the shoulder.

1. Coracobrachialis
2. Subscapularis tendon
3. Humeral head
4. Coracoid process
5. Deltoid muscle
6. Biceps tendon (long head)
7. Clavicle
8. Acromioclavicular joint
9. Supraspinatus muscle
10. Acromion
11. Infraspinatus muscle
12. Deltoid muscle
13. Teres minor muscle 28
 MRI of the shoulder
Coronal T1-weighted view

29
MRI of the shoulder.

1. Acromion
2. Infraspinatus muscle
3. Deltoid muscle
4. Teres minor muscle
5. Teres major muscle
6. Tricipital muscle
7. Humerus

30
MRI of the shoulder.

1. Trapezius muscle
2. Acromion
3. Deltoid muscle
4. Humeral head
5. Infraspinatus muscle
6. Teres minor muscle
7. Teres major muscle
8. Tricipital muscle
Arrow: Posterior humeral
circumflex artery and axillary nerve

31
MRI of the shoulder.

1. Trapezius muscle
2. Acromion
3. Infraspinatus tendon
4. Deltoid muscle
5. Humeral head
6. Infraspinatus muscle
7. Teres minor muscle
8. Teres major muscle
9. Tricipital muscle

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MRI of the shoulder.

1. Trapezius muscle
2. Acromion
3. Deltoid muscle
4. Humeral head
5. Supraspinatus muscle
6. Spine of the scapula
7. Infraspinatus muscle

33
MRI of the shoulder
Coronal T2

34
MRI of the shoulder. Coronal T2 FATSAT. Image 5

1. Trapezius muscle
2. Acromion
3. Deltoid muscle
4. Humeral head
5. Supraspinatus muscle
6. Spine of scapula
7. Infraspinatus muscle

35
MRI of the shoulder. Coronal T2 FATSAT. Image 6

1. Trapezius muscle
2. Acromioclavicular joint
3. Acromion
4. Deltoid muscle
5. Humeral head
6. Supraspinatus muscle
7. Spine of scapula
8. Infraspinatus muscle
9. Scapula
10. Subscapularis muscle
11. Teres major muscle
36
MRI of the shoulder. Coronal T2 FATSAT. Image 7

1. Trapezius muscle
2. Clavicle
3. Acromioclavicular joint
4. Acromion
5. Supraspinatus tendon
6. Greater tuberosity
7. Humeral head
8. Supraspinatus muscle
9. Glenoid
10. Spine of scapula
11. Infraspinatus muscle
12. Scapula
13. Subscapularis muscle
14. Teres major muscle

37
MRI of the shoulder. Coronal T2 FATSAT. Image 9

1. Trapezius muscle
2. Clavicle
3. Acromioclavicular joint
4. Deltoid muscle
5. Greater tuberosity
6. Humeral head.
7. Glenoid
8. Supraspinatus muscle
9. Subscapularis muscle
10. Teres major muscle

38
MRI of the shoulder. Coronal T2 FATSAT. Image 10

1. Trapezius muscle
2. Clavicle
3. Supraspinatus tendon
4. Deltoid muscle
5. Greater tuberosity
6. Humeral head
7. Glenoid
8. Supraspinatus muscle
9. Subscapularis muscle
10. Biceps and coracobrachialis

39
 MRI of the shoulder
Axial T1-weighted view

40
MRI of the shoulder. Axial T1-weighted view. Image 1

1. Axillary vein and artery

2. Clavicle
3. Acromioclavicular joint
4. Acromion
5. Supraspinatus muscle

41
MRI of the shoulder. Axial T1-weighted view. Image 2

1. Axillary vein and artery

2. Deltoid muscle
3. Coracoid process
4. Supraspinatus muscle
5. Acromion

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MRI of the shoulder. Axial T1-weighted view. Image 3

1. Pectoralis major muscle

2. Axillary vein and artery
3. Coracoid process
4. Deltoid muscle
5. Supraspinatus muscle
6. Acromion
7. Scapula
8. Subscapularis muscle

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 Pathologies
• Rotator Cuff

• Biceps tendon

• Labrum and capsule

• Osseous structures

• Arthritis

• Neural impingement

• Tumors

• Miscellaneous
 Rotator cuff

• Tendinopathy
• Partial tears
• Full thickness tears
• Calcific tendinitis
Partial tears
Full thickness tears
Bald spot sign
Arthritis
 Osteoarthritis
 Glenohumeral joint
 Acromio-clavicular joint (AVC)

• Relatively uncommon compared to

impingement
• Older patients
• Younger patients (post trauma / post surgery)
 Radiography
• Joint space narrowing
• Osteophytes
• Subchondral cysts and sclerosis
 MRI
• Subchondral cyts
• Osteophytes (marrow signal extends into it)
• Generalized thinning of hyaline cartilage, with
occasional focal defects
• Synovitis
• Loose bodies
• Posterior glenoid wear leads to increased
retroversion of glenoid
 Rheumatoid arthritis
• Synovium – articular cartilage – subchondral bone
• Marginal erosions (more at greater tuberosity)
• Bilateral symmetrical involvement
• Diffuse synovial thickening
• Joint effusion
• Bone erosions
• Loss of joint space not prominent
• Mild superior migration of humeral head ( decreased space.
• Clavicular erosions predominate at AC joint
• Tapered and resorbed distal clavicle (chronic cases)
 Miscellaneous Pathologies
• Dislocations
• Fractures
• Tumors
• AC separation
 Dislocation
Types
• Shoulder dislocations are usually divided
according to the direction in which the humeral
exits the joint:

• anterior : > 95 % (subcoracoid)

• posterior : 2 - 4 %
• inferior (luxatio erecta) : < 1 %
Anterior Dislocation
Anterior Dislocation
 Posterior dislocation

Axillary view

AP

Scapular ‘Y’ view

 Conclusion
• Plain radiographs are useful as an initial screening test with patients
with shoulder pain.

• Ultrasound may be used for diagnosing rotator cuff disease (> 90 %

sensitive and specific for tears).

• CT useful only in cases of trauma and to detect associated bony

abnormalities

• MRI is the ‘modality of choice’ for most of the shoulder pathologies.

• MR arthrography or CT arthrography is required for investigating

instability