US and MR imaging of Rotator Cuff

Pathology

Paulus Rahardjo
MSK Consultant Radiologist
Dr. Soetomo Hospital Medical Faculty-Airlangga
University
The SHOULDER Joint
The SHOULDER
Humeral head
articulates against a
shallow glenoid fossa
that covers only 1/3
of its surface
This configuration
permits greater range
of motion than any
other joint in the body
However, it provides
minimal stabilization
Pain and impairment of the
shoulder are commonly
associated with rotator cuff
pathology
HISTORY
Codman EA. The shoulder. Boston, MA:
Thomas Todd, 1934:123177

Medscape
RC PATHOLOGY SYMPTOMS
Rotator Cuff Pain (and Referred Pain) Pattern
WHAT IS THE IMAGING
CHOICE?
Review: Imaging Recommendations for
the Shoulder from International Clinical
Guidelines.
European commission referral
guidelines for imaging (2000)
ACC 2004
Department of Health Western
Australia (2007)
The Royal College of
Radiologists (RCR), London
(2007)
Bussieres et al 2008
This report is based upon information supplied up to 31 December 2010
Royal Australian & NZ
College of Radiologists
(RANZCR) Imaging Guidelines
(2001)
American College of Radiology
(ACR) Appropriateness Criteria
for Musculoskeletal Imaging
(2010).
 IMAGING RECOMMENDATION for
Non traumatic shoulder pain, and full or
limited movement
X-Ray_ general indications;
no response to 4 weeks conservative treatment,
significant activity restriction for more than 4 weeks,
non mechanical pain, or the presence of red flags
MRI is considered the gold standard for shoulder imaging
The guidelines consistently recommend MRI or US equally for
nontraumatic shoulder pain.
US is more cost effective than MRI but use is largely dependent on
local expertise and availability.

Shoulder Imaging review of existing guidelines. Bowens (2011),

Literature Search from : Databases of Medline, National Guideline Clearinghouse, NHS
Guideline finder and the TRIP database for the period 2005 to 2010
 Prevalence of pathology
identified on x-ray

Patients presenting to their primary care

practitioner (general practitioner (GP) or physiotherapist)
for the first time

Cadogan et al. BMC Musculoskeletal Disorders 2011, 12:119

US ACCURACY
Is US as accurate as MRI?
Ultrasonography vs. MRI
Have comparable degrees of accuracy
The choice should not be based on :
the strengths and weaknesses of each test
the clinical information being sought (lablar, capsular,
ligamentous, or bone pathology) MRI
the imaging experience at the individual institution
patient concerns
cost
Sensitivity of US for RC tear
Sensitive for:
full-thickness rotator cuff tears

Less sensitive for:

partial-thickness rotator cuff tears

Teefey SA, Hasan SA, Middleton W et al. J Bone Joint Surg Am 2000: 82:498-504
 Detection of rotator cuff tears: the
value of MRI following ultrasound

In patients who underwent surgery, US and MRI

yielded comparably high sensitivity for detecting
full-thickness RCT.
The additional value of MRI was in detecting
intra-articular lesions.
US performed better in detecting partial-
thickness tears, although the difference was not
significant.

Mathieu JC, et al. Eur Radiol. 2010 February; 20(2): 450457.

Prevalence of pathology identified
on ultrasound scan

Cadogan et al. BMC Musculoskeletal Disorders 2011, 12:119

Objectives:
US shoulder anatomy &
technique
Ultrasonographic
findings of RC
pathology corelated with
MRI
Pitfalls of RC pathology
Non RC pathology
US SHOULDER ANATOMY &
TECHNIQUE
 Glenohumeral joint
is stabilized by a group of tendons
working together
by forming a structure
called rotator cuff
Rotator Cuff (RC)
consist of (tendons):

1. Supraspinatus
2. Infraspinatus
3. Teres Minor
4. subscapularis
cuff

cuff
Rotator Cuff
Rotator Cuff
Supraspinatus (S)
Infraspinatus (I) GT
Teres minor (T) LT
Subscapularis (s) IS
S
TI s
T
Mnemonic: SITS
+
(Long Head) of
Biceps Tendon
 Rotator Cuff
Insertion and
biceps tendon LT
GT

Clark CM, Harryman DT. J Bone and Joint Surg., 74A(5):713-725,1992.

Very close relationship between
RC and Biceps tendon
ULTRASONOGRAPHY
TECHNIQUES
Ultrasonography of the rotator cuff

First described in 1977 to detect joint effusion

By early 1980s, high resolution transducers
made direct imaging of the rotator cuff
possible.
This examination is:
low-cost,
more available
great flexibility
easily imaged both shoulders.
also performs dynamic evaluation. [1,5]
Ultrasonographic Technique
Equipment:
History
Communication
Visualization
Linear array of
transducer
both joints
in
Variable high-
orthogonal
frequency
views
>7.5megahertz
Biceps Tendon (Short Axis)

LT
GT
Biceps Tendon (Short Axis)

Aniso
trophy
Anisotrophy
Anisotrophy
Biceps Tendon (Long Axis)

BT
(biceps
Tendon)

Transducer turned 90o

for longitudinal imaging
Subscapularis (Long Axis)
Subscapular
Supraspinatus
Technique/ Position:

Arm lock

Hand on back pocket

Karate

Next: the US image

SST contraction in arm
abduction
 Supra-
spinatus
(long axis) GT

GT
SupraSpinatus Tendon
Supraspinatus (short axis)

SS
Short Axis Supraspinatus
Infraspinatus & Teres Minor
Technique/ Position:

Hand reaches out to

the contralateral
shoulder
Scan the back of the
patient
Infraspinatus tendon

infraspinatus
 infraspinatus

ANTERIOR
ROTATOR CUFF
PATHOLOGIES
Rotator cuff pathologies
Rotator cuff tear
Partial thickness tear
Bursal side
Articular side
Full thickness tear
Massive tear
Tendinosis
Calcifying tendinosis
Impingement
 ROTATOR CUFF TEAR
The majority of cuff tears: in
supraspinatus tendon.
Infraspinatus tear happens
when supraspinatus tears
extend posteriorly
The subscapularis tear
may have
- an isolated tear after:
shoulder dislocation, or .
- coexist with: large tears of
the supraspinatus
or dislocated biceps tendon.
Types of
R.Cuff
Tears
Types of
R.Cuff
Tears
Full-thickness Tear
Full-thickness Tear
 Full-thickness Tear

Focal defect
Anechoic (wet)
Uncovered
cartilage sign
Loss of convexity
(dry)
Massive tear
retraction under
acromion process
Wet + uncovered cartilage sign
Full Thickness Fluid in Bursa
 normal tear
FOCAL
Full thickness GT GT
tear
 Chronic ACJ impingemnt
AC joint causing SST tear
arthritis
SST Tear (Total to Massive)
SST Tear (Total to Massive)
Partial-Thickness Tear
(articular/joint side)
Partial-Thickness Tear
(articular/joint side)
Partial-Thickness Tear
(bursal side)
Partial-Thickness Tear
(intrasubstance)
 Partial Thickness rotator cuff
tears : Arthroscopic
Grade 1:
classification
Partial tear < 3mm deep

Grade 2:
Partial tear 3-6 mm deep,
depth not exceeding one-
half of the tendon thickness

Grade 3:
Partial tear > 6mm deep.

Ellman H, CORR, (254) 64-74, 1990

Subscapular Rupture
Usually coexist with
large tears of the
supraspinatus and
infraspinatus

Subscapularis may
have an isolated tear
after anterior
shoulder dislocation.

or with dislocated
biceps tendon. Clark CM, Harryman DT. J Bone and Joint Surg., 74A(5):713-725,1992.
Subscapular Rupture
tear
tear
Subscapular Rupture

tear
 Infraspinatus Rupture
Supraspinatus blends
with infrasinatus
By convention:
supraspinatus accounts
for the first 15 mm of
the cuff from BT
Tears extending
Lt. Infraspinatus Rupture
posteriorly,
believed to involve the
infraspinatus tendon
Tendinosis (DD: part. Thickness tear)
 Average Thickness
The average thickness of an intact rotator cuff
is approximately
There is a slight but not significant difference in
rotator cuff thickness between the dominant limb
and non dominant limb
The rotator cuff thickness is not related to age,
gender, or symptoms
SST Tendinosis
SSS Tendinosis
Calcific tendinosis and
enthesopathy
Enthesophyte
calcification
 Impingement Syndrome
Restricted space
between
coracoacromial arc
(above) and humeral
head (below)
Compressing the
passing through of
rotator cuff
SS Tendinosis + Partial thick. tear
SS Tendinosis + Partial thick. tear

AC JOINT
ARTHROPATHY
Dynamic Study for impingement
coracoid
Netral
SS

Abduction
 Dynamic
examination