Rotator Cuff and Biceps Pathology
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1 Rotator Cuff and Biceps Pathology Jon A. Jacobson, M.D. Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Disclosures: Consultant: Bioclinica Advisory Board: GE, Philips Book Royalties: Elsevier Not relevant to this talk Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Outline Rotator cuff tears: Primary and secondary signs Miscellaneous pathology Biceps tendon pathology Rotator Cuff Tear: Meta-analysis: 65 articles Full-thickness tears: MRA, MRI, US = in sensitivity (92 95%) MRA more specific Partial-thickness tears: MRA most sensitive (86%) and specific MRI (64%), US (67%) de Jesus, 2009; 192:1701 Rotator Cuff Tears Tears are hypoechoic / anechoic Indirect signs at ultrasound: Cortical irregularity: supraspinatus footprint If present on radiographs, 75% have tear Volume loss Massive tear: non-visualization AJR 1998; 171:229 Radiology 2004; 230:234 Rotator Cuff Abnormalities: Categories: Partial-thickness tear Articular-sided Bursal-sided Intrasubstance (or interstitial) Full-thickness tear Tendinosis 1
2 Supraspinatus: normal Supraspinatus Insertion Bursal Surface Articular Surface Greater Surface Footprint From: Siebold et al. RadioGraphics 1999; 19:685 Supraspinatus Tears: extent Supraspinatus Tears: extent Rim-rent Tear B B Partial Articular Partial Bursal From: Fundamentals of Musculoskeletal Ultrasound Intrasubstance Full thickness From: Fundamentals of Musculoskeletal Ultrasound Rotator Cuff Tear: Extent Partial-thickness: Interstitial Articular Bursal Articular SST Articular Partial-thickness Tear: supraspinatus Full-thickness, incomplete: Extends to two surfaces Full-thickness, complete: Entire tendon discontinuous Full width Coronal T2w 2
3 Pitfall Alert! Anisotropy Sound beam oblique to tendon fibers Artifactually hypoechoic Most common location for this error: rim rent area Bursal Partial-thickness Tear: supraspinatus Supraspinatus: long axis Coronal T2w Bursal Partial-thickness Tear: supraspinatus Full-thickness Tear: supraspinatus Note: Cartilage Interface Sign (open arrow) Full-thickness Tear: supraspinatus Large Full-thickness Tear: supraspinatus Deltoid IST 3
4 Intrasubstance Tear: supraspinatus Deltoid Humerus Tendinosis No inflammatory cells Mucoid degeneration, chondroid metaplasia Hypoechoic, ill-defined Possible increased thickness No cortical irregularity* From: Wilson JJ, et al. Am Fam Physician; 2005: 32:165 From: Hodler J, et al. J MRI; 2010: 72:811 *Note lack of cartilage interface sign *Radiology 2004; 230:234 Tendon Tear versus Tendinosis Tendinosis: supraspinatus *both may appear hypoechoic Tear Anechoic Well-defined Homogeneous Thinned Bone irregularity* Tendinosis Hypoechoic Ill-defined Heterogeneous Swollen Smooth cortex *At supraspinatus tendon footprint in patients over 40 years old Fatty Infiltration and Muscle Atrophy Supraspinatus and infraspinatus Infraspinatus: only variable to predict cuff healing 1 Associations: Chronic, large, anterior supraspinatus tears 2 Ultrasound: Comparable to MRI 3 Improved reliability with extended field-of-view 4 1 Chung et al. Am J Sports Med 2013; 41: Hodler et al. Radiology 2005; 237: Wall LB et al. JBJS 2012; 94:e83. 4 Nazarian et al. 2008; 190:27. Fatty Infiltration and Muscle Atrophy Indistinct tendon-muscle border Increased muscle echogenicity Compare to teres minor Decreased muscle bulk Compared to teres minor Bone landmark: ridge in scapula Short axis: infraspinatus 2x size 4
5 Atrophy: supraspinatus and infraspinatus No Atrophy Teres Minor Teres Minor Supraspinatus Infraspinatus (extended field-of-view) Supraspinatus Infraspinatus (extended field-of-view) Secondary Findings of Rotator Cuff Tears: Tendon Volume Loss Volume loss of tendon substance Cortical irregularity Effusion (articular & bursal) Cartilage interface sign Full-thickness Bursal Partial-thickness Cortical Irregularity: Greater tuberosity: at supraspinatus insertion When present: 75% have rotator cuff tears Patient over 40 years old When absent: 96% normal cuffs by sonography AJR 1998; 171:229 Radiology 2004; 230:234 Cortical Irregularity: no significance Humerus Subscapularis Tendon 5
6 Joint & Bursal Effusions: Joint effusion (biceps tendon) Subacromial-subdeltoid bursal fluid: >1 mm distention If both: 95% positive predictive value for rotator cuff tear* Joint Effusion and Bursal Fluid Deltoid *Hollister et al. AJR 1995; 165:605 Small Full-thickness Tear: supraspinatus Deltoid Miscellaneous Cuff Pathology: Infraspinatus tendon Subscapularis tendon Calcific tendinosis Humerus IST Infraspinatus Tear: full-thickness Greater SST Miscellaneous Cuff Pathology: Infraspinatus tendon Subscapularis tendon Calcific tendinosis 6
7 Partial-thickness Articular Tear: subscapularis Focal Full-thickness Tear: subscapularis Lesser Lesser Contralateral Subscapularis Tear: full-thickness Lesser Miscellaneous Cuff Pathology: Infraspinatus tendon Subscapularis tendon Calcific tendinosis Contralateral side Calcific Tendinosis Calcific Tendinosis Hydroxyapatite deposition: metaplasia Usually do not have cuff tear Appearance: 79% hyperechoic & shadowing No shadow: 7% Two phases: Formative Resorptive: painful Farin et al. Skeletal Radiol 1996; 25:551 Formative Defined, shadow Resorptive Amorphous, little shadow 7
8 Degenerative Calcification Biceps Brachii: pathology Tendinosis Tear: partial and full-thickness Subluxation and dislocation Association with: SLAP and anterior rotator cuff tears Causes: acute injury, repetitive injury, degeneration Biceps Tendon: Glenohumeral joint effusion: Collects around biceps tendon Tendon sheath communication Seen in 97% with joint effusion Abnormal: > 1 mm 1 Shoulder Joint Recesses Long head biceps tendon sheath Posterior recess: Image with shoulder in external rotation Axillary recess Subscapularis recess 1 Zubler et al. Eur Radiol 2011; 21:1858 Color Doppler Biceps Tendon Sheath Septic Joint Intra-articular body Echogenic Possible shadowing Single or multiple Associated with glenohumeral joint osteoarthritis Biceps tendon sheath distention Heterogeneous Increased blood flow Non-specific 8
9 Biceps Tendon: tenosynovitis Biceps Tendon Tendinosis: Hypoechoic Swollen No inflammatory cells (not tendinitis) Possible tenosynovitis Biceps Tendon: Partial-thickness tear: Hypoechoic /anechoic cleft Tenosynovitis Sensitivity: 27% Accuracy: 88% Subluxation / spur Skendzel Important J, et secondary al. AJR 2011; signs 197:942 Split + tenosynovitis Partial tear + tenosynovitis Subluxation + spur Aponeurotic Expansion of Supraspinatus Tendon Up to 49% of shoulders Cleft: coronal plane Origin: supraspinatus Distal: pectoralis or bicipital groove Moser et al. Skeletal Rad 2015; 44:223 Bicipital Groove Biceps Tendon: full-thickness tear Humerus Short Head : distal Pitfall Alert! Pseudo Biceps Tendon Biceps brachii long head Complete retracted tear Pseudofibers in groove Collapsed tendon sheath Aponeurotic expansion of supraspinatus Look for distal retracted tendon and absent tendon SST in rotator interval 9
10 Biceps Tendon Biceps Tendon Subluxation * Lesser * Lesser Subluxation Dislocation Biceps Tendon Dislocation Biceps Tendon: Dislocation into subscapularis tendon Take-home Points Must follow a protocol Most cuff tears: anterior supraspinatus Use rotator interval as landmark Cortical irregularity: important indirect sign Supraspinatus tears Dynamic: impingement, adhesive capsulitis Joint effusion: biceps, posterior Syllabus on line and other educational material: Twitter 10
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