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    Imaging of Chronic Non-Traumatic Shoulder Pain: Dr. Naveed Ahmed Fcps FRCR

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    Naveed Ahmed
    This document discusses imaging of chronic non-traumatic shoulder pain. It covers common causes like chronic impingement, instability, biceps tendon abnormalities, and adhesive capsulitis. Imaging recommendations are provided for conditions like impingement and rotator cuff tears. MRI is advantageous over ultrasound for diagnosing labral abnormalities and marrow edema, while ultrasound is cheaper and allows dynamic imaging. Specific techniques are described for ultrasound of structures like the biceps, supraspinatus, and subscapularis tendons.

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    Imaging of Chronic Non-Traumatic Shoulder Pain: Dr. Naveed Ahmed Fcps FRCR

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    Naveed Ahmed
    34 views70 pages
    This document discusses imaging of chronic non-traumatic shoulder pain. It covers common causes like chronic impingement, instability, biceps tendon abnormalities, and adhesive capsulitis. Imaging recommendations are provided for conditions like impingement and rotator cuff tears. MRI is advantageous over ultrasound for diagnosing labral abnormalities and marrow edema, while ultrasound is cheaper and allows dynamic imaging. Specific techniques are described for ultrasound of structures like the biceps, supraspinatus, and subscapularis tendons.

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    This document discusses imaging of chronic non-traumatic shoulder pain. It covers common causes like chronic impingement, instability, biceps tendon abnormalities, and adhesive capsulitis. Imaging recommendations are provided for conditions like impingement and rotator cuff tears. MRI is advantageous over ultrasound for diagnosing labral abnormalities and marrow edema, while ultrasound is cheaper and allows dynamic imaging. Specific techniques are described for ultrasound of structures like the biceps, supraspinatus, and subscapularis tendons.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    34 views70 pages

    Imaging of Chronic Non-Traumatic Shoulder Pain: Dr. Naveed Ahmed Fcps FRCR

    Uploaded by

    Naveed Ahmed
    This document discusses imaging of chronic non-traumatic shoulder pain. It covers common causes like chronic impingement, instability, biceps tendon abnormalities, and adhesive capsulitis. Imaging recommendations are provided for conditions like impingement and rotator cuff tears. MRI is advantageous over ultrasound for diagnosing labral abnormalities and marrow edema, while ultrasound is cheaper and allows dynamic imaging. Specific techniques are described for ultrasound of structures like the biceps, supraspinatus, and subscapularis tendons.

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    © All Rights Reserved
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    of 70

    Imaging of Chronic

    Non-Traumatic
    Shoulder Pain
    DR . NAVEED AHMED
    FCPS FRCR
    Chronic Shoulder Pain
    Chronic Impingement
    Chronic Instability.
    Long head of bicep tendon abnormalities.
    Adhesive capsulitis.
    Calcific tendinosis.
    Chronic Impingement
    Causes.
    Recommended views
    Ultrasound (Normal and pathologies)
    MRI (Normal and pathologies)
    MR Arthrography
    CT arthrography.
    Chronic Impingement
    Common Causes:
    Degenerative AC joint.
    Os Acromiale
    Thick coracoacromial ligament.
    Post traumatic osseous deformity.
    Instability.
    Recommended Views
    Recommended Views
    ACJ view (Zanca)
    Degenerative AC joint (Sourcil
    Sign)
    Degenerative Shoulder Joint
    High riding humerus with decreased acro-humeral
    distance
    Narrowing of acrohumeral space , 0.5 cm.
    Sclerosis of humeral head and acromion.
    Cystic lesions in acromion and head of humerus.
    Rotator Cuff Tear
    Radiographic abnormalities
    Acute
    Chronic rotator cuff tear
    ◦ Narrowing
    ◦ Acromiohumeral space
    ◦ Reversal of normal inferior acromial convexity
    ◦ Cysts and sclerosis of acromion and humeral
    head
    Hill sachs image
    Chronic Impingement (MRI vs
    Ultrasound)
    MRI ADVANTAGES ULTARSOUND ADVANTAGES

    Reproducible. Low cost


    Excellent soft tissue contrast, Multiplanar
    Can diagnose labral abnormalities and Dynamic imaging is possible
    Marrow infiltration / edema. Intra articular injections.

    Disadvantages: Disadvantages:
    Higher cost. Operator dependent.
    Chronic shoulder Pain
    (Positioning for US of the Biceps
    brachii)
    TRANSVERSE LONGITUDNAL
    Chronic shoulder Pain (US of the
    Biceps brachii)
    T/S L/S
    Tear of biceps
    brachii
    A-C JOINT Technique and image.
    Chronic shoulder pain (U/S of
    the supraspinatous muscle)
    L/S L/S
    Chronic Shoulder Pain
    (Suprasinatpous)
    SSP TENDINOSIS SSP PARTIAL THICKNESS TEAR
    Chronic Shoulder Pain
    (Suprasinatpous)
    Chronic Shoulder Pain
    (Suprasinatpous)
    FULL THICKNESS TEAR OF SSP PARTIAL THICKNESS TEAR OF SSP
    subscapularis
    Infraspinatous tendon
    Joint effusion
    Calcific tendinosis
    MRI ANATOMY
    Recommended sequences
    MR ANATOMY (axial)
    MR ANATOMY (axial)
    MR ANATOMY (axial)
    MR ANATOMY (Coronal)
    MR ANATOMY (Coronal)
    MR ANATOMY (coronal)
    MR ANATOMY (sagittal)
    MR ANATOMY (sagittal)
    MR ANATOMY (sagittal)
    Chronic Impingement
    Chronic shoulder Instability
    Rotator Cuff Tear

    1. Supraspinatus muscle
    2. Infraspinatus muscle
    3. Subscapularis muscle
    4. Teres minor muscle
    Chronic shoulder Instability
    Chronic Impingement
    Rotator Cuff Tear
    MR Abnormalities:
    Full thickness tear: High SI on T2WI
    Direct signs
    Tendon Discontinuity
    Fluid signal in tendon gap
    Retraction of musculotendinous junction
    Associated findings
    Subacromial / subdeltoid bursal fluid
    Muscle atrophy
    Chronic shoulder Instability
    Magic angle Phenomenon

    Collagen fibers: oriented at about 55 degress to main magnetic field

    Specific location: 1 cm from insertion of supraspinatus tendon on greater tuberosity


    Chronic Impingement (Acromial
    configuration)
    Chronic Impingement (Os
    acromiale)

    Fat sat T2WI


    Chronic shoulder Instability
    Rotator Cuff Tear
    Classification
    Full thickness tear
    Articular bursal surface
    Complete / incomplete
    Partial thickness tear
    Articular / bursal / intratendinous
    Massive tear: full thickness tears involving multiple tendons of the rotator cuff
    Chronic shoulder Instability
    Rotator Cuff Tear

    Prevalence

    Partial thickness tear > full thickness tear


    Articular side > bursal side > intratendinous
    Chronic shoulder Instability
    Rotator Cuff Tear

    Repetitive microtrauma > acute trauma


    Full thickness tear occurred by combination of
    ◦ Age
    ◦ Repetitive stress / impingement syndrome
    ◦ Corticosteroid injection
    ◦ Hypovascularity
    ◦ DM
    Chronic shoulder Instability
    Rotator Cuff Tear

    Men
    > 40 years
    Dominant arm

    Partial thickness: pain


    Full thickness: pain, limited ROM
    Coracoacromial arch:
    1. Anterior third of acromion
    2. Coracoacromial ligament
    3. Coracoid process
    ↕
    Impingement Interval
    1. Rotator cuff tendons
    2. Long head biceps tendon bursa
    3. Coracohumeral ligament
    ↕
    Humeral head
    Effects of impingment

    Bones
    Degenerative cysts, sderosis of greater tuberosity & / or humeral head
    Bursa
    Subacromial / subdeltoid bursitis
    Tendons
    Supraspinatous tendon
    Proximal long head biceps brachii tendon
    ◦ Degeneration
    ◦ Partial tear
    ◦ Complete tear
    Rotator Cuff Tear

    Arthrographic abnormalities

    Complete tear: Abnormal communication between glenohumeral joint cavity & subacromial (subdeltoid)
    bursa
    Interstitial tear & bursal surface tear of cuff → not demonstrated on glenohumeral joint arthrogram
    False negative in partial tear: too small lesion, a fibrous nodule has occluded defect
    Rotator Cuff Tear

    MR Abnormalities
    Partial thickness tear
    ◦ Increased SI on T1 & T2
    ◦ Higher signal than muscle on T2
    (similar to joint fluid)
    ◦ Tear on joint surface fills with Gd on
    MR arthrogram
    Degeneration
    ◦ Intrasubstance increased S1 T1 & T2
    ◦ Not as high signal as joint fluid
    Adhesive capsulitis
    (Frozen shoulder)

    Inflammatory process → progressive capsular retraction, scar tissue


    F>M
    Causes:
    Idiopathic, Trauma, Immobilization, DM
    Symptoms:
    Pain at rest, at night, and motion
    Limitation of movement (abduction and external rotation)
    Adhesive capsulitis
    (Frozen shoulder)
    Freezing – painful stage: acute synovitis (3 – 9 months)
    Progressive, pain worsens & restricted ROM
    Frozen – transitional stage: (4 – 12 months)
    Stable pain due to limited ROM
    Thawing stage: (12 – 42 months)
    Begins when ROM begins to improve
    Gradual return of shoulder mobility
    Adhesive capsulitis
    (Frozen shoulder)
    MRI:
    Complete obliteration of the fat triangle under the coracoid process (subcoracoid triangle sign)
    Scar tissue
    Thickening of the CHL
    Axillary recess thickening
    Arthrography:
    Decreased joint capacity
    Small capsular recesses
    Serrated appearance of capsular attachments
    Chronic Impingement
    Long Head of Biceps Tendon
    Tear / Degeneration
    Proximal to bicipital groove.
    Associated with impingement
    Associated with supraspinatus tear
    Older population
    Musculotendinous junction
    Acute, Traumatic injury
    Younger population
    Long Head of Biceps Tendon
    Dislocation
    Associated disruption
    Transverse humeral ligament
    Usually subscapularis tendon
    MRI
    Empty bicipital groove (axial)
    Tendon displaced medially
    Subcapularis tendon avulsed from tuberosity
    Infraspinatus Tendon Tear

    Isolation after acute trauma


    Associated with posterosuperior impingement

    Infraspinatus tendon, posterosuperior labrum &


    humeral head
    Overhead movement with abduction & external rotation
    Posterosuperior pain & anterior instability
    Infraspinatus Tendon Tear

    MRI
    Infraspinatus tendon undersurface tears
    Posterosuperior labral tear
    Humeral cyst adjacent to infraspinatus tendon
    insertion
    Adhesive Capsulitis
    Acromiohumeral interval (AHI)

    True AP shoulder radiograph

    > 12 mm – shoulder dislocation, subluxation


    9 – 10 mm (range 8 – 12 mm) – Normal
    6 – 7 mm – thinning of supraspinatus tendon
    <6 mm – supraspinatus tear
    Structural factors

    Acromioclavicular (AC) joint


    Congenital anomalies or degenerative joint (osteophytes)
    Acromion
    Alterations in shape, malunion or nonunion, os acromiale or
    osteophytes
    Coracoid process
    Congenital anomalies, post traumatic / surgical changes
    Thickening of coracoacromila ligament: no related to
    impingement
    Structural factors

    Subacromila – subdeltoid bursa


    Inflammation, thickening, foreign bodies
    Rotator cuff
    Calcification, thickening
    Irregularity related to tendon tears or postoperative / traumatic
    scars
    Over development: athletes
    Humerus
    Congenital anomalies, malunion or altered position of a humaeral
    head prosthesis
    Classification of impingement
    Primary impingemen:
    Alterations in coracoacromial arch
    Non-atheletes
    Subacromial impingement External impingement
    Coracoid impingement External impingement

    Secondary impinmgement:
    Related to either glenohumeral or scapular instability
    Mainly in athletes: overhead movement of arm
    Glenohumeral instability External impingement
    Posterosuperior impingement Internal impingement
    Anterosuperior impingement Internal impingement

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