By David W Stoller; et al
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Extra resources for Orthopaedics
Ultrasonographic Findings Focal tendon interruption Fluid-filled gap (hypoechoic) Loss of convexity of tendonlbursa interface Hypoechoic tendon Tendon retraction Uncovered cartilage sign Calcium = hyperechoic foci + shadowing Imaging Recommendations Best imaging tool: MRI Protocol advice o FS PD FSE & T2 FSE FS PD FSE more sensitive for tendinosis T2 FSE more specific for tears . I Overuse, degeneration and complete tearing of RTC +/- Secondary to impingement (hooked acromion, overuse) or acute trauma Shoulder pain 7-25% of general population o Coronal, sagittal and axial images I DIFFERENTIAL DIAGNOSIS lntratendinous Cyst Thickened tendon Cyst (hyperintense mass) visible on T2WI o Cyst usually flattened Associated with partial tear of the cuff Partial Tear of Rotator Cuff Incomplete tendon defect Fluid within not traversing tendon Hyperintense partial defect on T2WI o Bursal, interstitial, articular Low grade (superficial), intermediate grade (< 50% of cuff thickness), and high grade (> 50% of cuff thickness) Adhesive Capsulitis Thickened hyperintense capsule o Axially pouch inferior glenohumeral ligament (IGHL) involved o Rotator interval (synovitis) Frozen shoulder +/- Cuff tear Acromioclavicular Arthritis Anterosuperior pain Lidocaine injection challenge - diagnostic Hyperintense edema on T2WI Chondromalacia (hyperintense T2 +/- defects) +/- Hyperintense T2 subchondral cysts Rheumatoid Arthritis (RA) Inflammatory arthritides Hyperintense (PD/T2) synovitis o Thickened synovium +/- Rice bodies o Bursae +/- Rheumatoid factor I ROTATOR CUFF FULL THICKNESS TEAR Rotator Cuff Tendinopathy Thickened (T2WI) cuff tendons o Hyperintense on FS PD FSE o Intermediate on T2 FSE +I- Impingement No tear +/- Chronic repetitive microtrauma/impingement Presentation Most common signslsymptoms o Pain with impingement test Hand on unaffected shoulder and gradual forward flexion of the affected shoulder Clinical profile o Insidious onset of pain, continuously increases with time - impingement o Pain in athletics - internal impingement - younger patient, athlete, occupation o Continued pain post trauma General Features General path comments: Tear occurring in otherwise degenerated tendon due to chronic overuse Etiology o Overuse, degeneration and complete tearing of RTC o +/- Secondary to impingement (hooked acromion, overuse) or acute trauma o Collagen vascular diseases with tears of other tendons o Acutely in the setting of preexisting tendinosis, acute trauma Epidemiology o Shoulder pain 7-25% of general population Full thickness tears - lower percentage o Shoulder pain in 10/1000 population Peaks at 2511000 population (42-46 years) o > 60 years - 28% demonstrate full thickness tears o Cadaver studies: Incidence of full thickness tears 18-26% o MRI studies: Tears in 34% of asymptomatic individuals of all ages Associated abnormalities o Hill-Sachs deformity - anterior dislocation o Patients > 40 years supraspinatus tear after anterior dislocation o Biceps tendinosis/tears/SLAP lesions with microinstability .
Left) Sagittal FS PD FSE MR shows tearing of the posterior supraspinatus and infraspinatus (arrow) in a patient with posterosuperior (internal) glenoid impingement (PSCI). (Right) Axial FS PD FSE MR shows a full thickness tear (arrow) of the supraspinatus tendon. ROTATOR BNTERVAL TEARS Coronal graphic shows a tear of the bursa1 aspect of the rotator interval (coracohumeral ligament component). The biceps tendon is visualized through the tear. Coronal PD FSE MR shows a tear of the rotator interval with tendinosis of the biceps tendon (arrow).
2. 3. 4. 5. Teefey SA et al: Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 82(4):498-504,2000 Gartsman GM: Arthroscopic management of rotator cuff disease. J Am Acad Orthop Surg 6(4):259-66, 1998 Cohen RB et al: Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clin Orthop (351):95-101,1998 Fritz RC et al: MR imaging of the rotator cuff. Magn Reson Imaging Clin N Am 5(4):735-54,1997 Neer CD et al: Cuff-tear arthropathy.
Orthopaedics by David W Stoller; et al