Imaging of degenerative and posttraumatic disease in the shoulder joint with ultrasound

This article reviews the examination technique of shoulder ultrasound, normal and abnormal ultrasound findings in acute (posttraumatic) and chronic (degenerative) lesions. Moreover, it reviews the effectiveness of ultrasound in relation to magnetic resonance (MR) imaging. Most authors report that full-thickness tears of the supraspinatus can reliably be diagnosed by ultrasound. However, the simple diagnosis of a full-thickness rotator cuff tear is no longer sufficient for surgical management. The precise localization and size of rotator cuff tears as well as the extent of muscle degeneration is important for surgical planning. For this aspect and for partial-thickness tears of the supraspinatus, for subscapularis lesions as well as for lesions of the long biceps tendons there is no consensus regarding the diagnostic value of ultrasound. To the present, ultrasound (contrary to MR imaging) has failed to demonstrate that it consistently influences the clinician's degree of confidence in the clinical diagnosis or the treatment plan. Therefore, some orthopedic surgeons prefer MR imaging to ultrasound in the evaluation of rotator cuff tears and other abnormalities of the glenohumeral joint. Moreover, MR imaging, especially when combined with arthrography, represents a one-step investigation, which not only allows for assessment of rotator cuff lesion but also of lesions of the labrum (Bankart lesions, SLAP lesions), the joint capsule and the biceps tendon. It also demonstrates muscle atrophy, which represents an important predictor of surgical outcome in rotator cuff repair.     

Lesions of the reflection pulley of the long biceps tendon. MR arthrographic findings.

RATIONALE AND OBJECTIVES: The purpose of this study was to assess the diagnostic value of MR arthrography in detecting a lesion of the common insertion of the coracohumeral and the superior glenohumeral ligaments and the superior border of the subscapularis tendon (pulley lesion), which predisposes to biceps tendon subluxation and subsequent degeneration. METHODS: Parasagittal T1-weighted turbo spin-echo and axial gradient-echo (three-dimensional fast imaging with steady state-precession [FISP]) MR arthrographic images were obtained in 14 patients with surgically confirmed pulley lesions and in 10 patients with an intact pulley. Various MR arthrographic signs potentially associated with a pulley lesion were evaluated separately and independently in a blinded fashion by two radiologists. RESULTS: Abnormalities of the superior border of the subscapularis tendon on axial and parasagittal images, extra-articular contrast collection, and biceps tendon subluxation were the MR findings of a pulley lesion. The coracohumeral and superior glenohumeral ligaments were not readily visible in all patients and were not helpful in diagnosing pulley lesions in this study. The overall sensitivity for detecting a pulley lesion by MR arthrography was 86% and 93% for readers 1 and 2, with a specificity of 100% and 80% and an accuracy of 92% and 87% (kappa = 0.75). CONCLUSIONS: Based on the authors' experience, MR arthrography is valuable in detecting lesions of the reflection pulley of the long biceps tendon, although differentiation from an isolated lesion of the superior border of the subscapularis tendon may not be possible.     

Assessment of the long head of the biceps tendon of the shoulder with 3T magnetic resonance arthrography and CT arthrography

We studied the assessment of proximal biceps tendon lesions including degeneration, tendon luxation, and partial and complete tendon tears with 3T MR arthrography and CT arthrography. Thirty-six patients who underwent both studies, as well as arthroscopy were included in the study. The images were randomized and blinded and independently reviewed by two musculoskeletal radiologists. The pooled sensitivity for lesion detection for CT arthrography was 31% and the specificity 95%. The pooled sensitivity for MR arthrography was 27% and the specificity 94%. There were no statistically significant differences between CT and MR. The interobserver agreement calculated with the kappa statistic was poor for CT and for MR. Both CT arthrography and MR arthrography perform poorly in the detection of biceps tendon pathology of the shoulder.     

Clinical impact of MR arthrography of the shoulder.

PURPOSE: To evaluate the effect of MR arthrography of the shoulder on diagnostic thinking and therapeutic decisions by orthopedic shoulder surgeons. MATERIAL AND METHODS: Orthopedic surgeons completed a questionnaire before and after MR arthrography for 73 consecutive patients. The main indications were suspected rotator cuff abnormalities. The clinical diagnosis, the degree of confidence in this diagnosis, and the therapeutic decision were noted before and after MR imaging. Surgical reports were available for 34 patients. RESULTS: Thirty-four percent of the pre-MR imaging diagnoses were withdrawn after MR imaging, and new diagnoses were made after MR imaging in 13% of the cases. Confidence in the diagnosis increased significantly after MR imaging for supraspinatus and infraspinatus lesions (p<0.05). Changes of therapeutic decision after MR imaging were noted in 36 of the 73 patients (49%). In 23 patients, more invasive therapeutic procedures were initiated after MR imaging, and a more conservative treatment was implemented for 13 patients. Agreement of MR diagnoses with surgery was 94% for supraspinatus tears, 87% for infraspinatus tears, 77% for subscapularis tears, and 81% for biceps tendon lesions. Agreement of clinical diagnoses with surgery was 56%, 83%, 50%, and 64%, respectively. CONCLUSION: MR arthrography of the shoulder has a major effect on diagnostic thinking and therapeutic decisions by orthopedic shoulder surgeons.     

Magnetresonanztomographie der Schulter

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.     

MR imaging of the shoulder. Impingement and instability-related abnormalities

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.     

Imaging findings in the dominant shoulder of throwing athletes: comparison of radiography, arthrography, CT arthrography, and MR arthrography with arthroscopic correlation

OBJECTIVE: Conventional radiography, arthrography, CT arthrography, and MR arthrography--including use of the abduction and external rotation position--were compared, with arthroscopic correlation, to determine the spectrum of abnormalities encountered and the relative benefits of each imaging method in the evaluation of shoulder lesions occurring in 17 throwing athletes. SUBJECTS AND METHODS: Each of 36 athletes with shoulder pain aggravated by abduction and external rotation was examined in a single visit during which conventional radiography, arthrography, CT arthrography, and MR arthrography were performed. In 17 of these athletes, imaging findings were compared with those at arthroscopy. All images were independently evaluated by two groups of musculoskeletal radiologists. RESULTS: Structures found to be affected were, in decreasing order of frequency, the following: the posterosuperior labrum, supraspinatus tendon, infraspinatus tendon, humeral head, glenoid cavity and rim, acromioclavicular joint, anteroinferior capsulolabral complex, biceps tendon, and subscapularis tendon. MR arthrography without and with abduction and external rotation yielded the highest sensitivity and specificity for all lesions with the exceptions of bone sclerosis and enthesophytes (which were best seen with CT arthrography). MR arthrography with abduction and external rotation was most accurate for diagnosis of rotator cuff and anteroinferior capsulolabral complex tears. CONCLUSION: On the basis of these preliminary results, we believe that MR arthrography with abduction and external rotation should be part of the imaging evaluation of shoulder pain in throwing athletes, owing to the high sensitivity of this imaging technique.     

Rotator cuff lesions: evaluation with RM and US

Physical and instrumental examination of the patients with an "aching shoulder" is often difficult and a positive out-come of surgical treatment may be impaired by the late diagnosis of long-standing rotator cuff lesions causing tendon adhesions and muscle atrophy. The authors report the results obtained in 25 selected patients with an aching shoulder examined with arthrography, real-time ultrasound (US) with a 5 MHz linear probe, and high-field (1.5 T) Magnetic Resonance (MR) imaging. Arthrography was able to demonstrate a cuff tear in 14/25 cases; US detected signs of tear in 14/25 (1 false negative); MR imaging showed a cuff lesion in 16/25 patients, and in one case allowed a partial cuff tear to be demonstrated, which had not been visualized with arthrography. MR imaging could also demonstrate other signs of periarticular pathologies (tendinitis, longhead of biceps inflammation, and bursitis) that may represent the early stages of the inflammatory-degenerative process underlying most of cuff lesions. The high diagnostic accuracy of US (95%) is stressed in the detection of cuff tears, in patients with an aching shoulder; as for questionable cases at US, MR imaging is indicated as a valid alternative to arthrography, which is more invasive and less accepted by the patients.     

Evaluation of Rotator Cuff Tendon Tears: Comparison of Multidetector CT Arthrography and 1.5-T MR Arthrography

Purpose: To compare the diagnostic performance of multidetector computed tomographic (CT) arthrography and 1.5-T magnetic resonance (MR) arthrography in the evaluation of rotator cuff lesions, with arthroscopic correlation. Materials and Methods: This study was approved by the institutional ethical committee, and informed consent was obtained from all patients. CT and MR arthrographic images prospectively obtained in 56 consecutive patients, following the same arthrographic procedure, were independently evaluated by two radiologists. Arthroscopy, performed within 1 month of the imaging, was used as the reference standard. Sensitivity and specificity of CT and MR arthrography were compared by using the McNemar test. Interobserver and intertechnique agreement for detecting rotator cuff lesions were measured and compared with κ and Z statistics. The Bland-Altman method was used to determine interobserver and intertechnique agreement for measuring tendon tears. For grading fatty infiltration of rotator cuff muscles, κ and Z statistics were used. Results: There was no statistically significant difference in sensitivity and specificity between CT arthrography and MR arthrography in depiction of rotator cuff lesions. The respective sensitivity and specificity of CT arthrography were 92% and 93%-97% for the supraspinatus, 100% and 77%-79% for the infraspinatus, 75%-88% and 85%-90% for the subscapularis, and 55%-65% and 100% for the biceps tendon. The respective sensitivity and specificity of MR arthrography were 96% and 83%-93% for the supraspinatus, 88%-100% and 81%-83% for the infraspinatus, 75%-88% and 90%-100% for the subscapularis, and 65%-85% and 100% for the biceps tendon. Interobserver agreement was substantial to almost perfect (κ = 0.744-0.964 for CT arthrography; κ = 0.641-0.893 for MR arthrography), and intertechnique agreement was almost perfect (κ > 0.819). CT and MR arthrography both yielded moderate interobserver and intertechnique agreement for measuring rotator cuff tears and grading muscle fatty infiltration. Conclusion: Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. ? RSNA, 2012.     

Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder. MATERIALS AND METHODS: From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography. RESULTS: SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography. CONCLUSION: MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.     

Diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder

OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior (SLAP) lesions of the shoulder with emphasis on the classification of SLAP lesions. MATERIALS AND METHODS: Two hundred sixty-five MR arthrograms including 68 MR arthrograms of patients with arthroscopically proven SLAP lesions of the shoulder and 197 MR arthrograms of patients with an intact superior labrum and biceps anchor were retrospectively reviewed in random order. MR arthrography was performed using triplanar T1-weighted spin-echo sequences and a coronal oblique T2-weighted fast spin-echo sequence. MR arthrograms were evaluated by two radiologists with agreement by consensus, and the results were compared with arthroscopic findings. RESULTS: Of 68 SLAP lesions, seven (10%) were arthroscopically classified as type I, 41 (60%) as type II (including 20 type II lesions with coexisting Bankart lesions [29%]), 14 (21%) as type III, and six (9%) as type IV. Compared with arthroscopy as the gold standard, MR arthrography showed a sensitivity of 82% and a specificity of 98% for the overall detection of SLAP lesions. MR arthrographic grading and arthroscopic grading were concurrent in 45 (66%) of 68 arthroscopic diagnoses. Of the surgically confirmed SLAP lesions, involvement of the biceps insertion and SLAP type II lesions with coexisting Bankart lesions were assessed correctly in 75% and 95% of cases, respectively. CONCLUSION: MR arthrography is a highly effective method for the detection of SLAP lesions, but this technique is limited in the classification of different types of SLAP lesions. However, for preoperative planning MR arthrography provides accurate information about the stability of the biceps insertion and the presence of associated anteroinferior labral injuries.     

MR arthrographic findings in tenosynovitis of the long bicipital tendon of the shoulder

 Purpose. To assess the MR arthrographic findings of bicipital tenosynovitis in correlation with arthroscopy. Design and patients. The shoulder MR arthrographies of 500 consecutive patients were retrospectively analyzed for signs of bicipital tenosynovitis and associated pathologies. Forty patients (8%) had MR evidence of bicipital tenosynovitis, but only 17 (3%) with arthroscopic confirmation were included in the study. The MR findings in these patients were compared with those of 10 patients with rotator cuff lesions but arthroscopically normal long biceps tendons. MR arthrography was performed with 10–15 ml of a 250 mmol/l gadoterate meglumine (Gd-DOTA) solution injected under fluoroscopic guidance, and transaxial, oblique coronal and sagittal MR sequences were obtained. Results. All 17 patients showed one or more abnormal findings: signal increase in the tendon with or without fusiform distension was seen in 12, surface irregularities in six, adhesions in 11 and noncommunicating effusions of the tendon sheath in six. Associated abnormalities of the rotator cuff were present in 16 while the seventeenth patient had glenohumeral synovitis without rotator cuff pathology. MR arthrograms correlated with arthroscopic findings in the joint but comparison was not possible in the intertubercular groove portion of the biceps tendon. None of the 10 patients with an arthroscopically normal biceps tendon showed any of the MR findings of bicipital tenosynovitis. Conclusion. Bicipital tenosynovitis is detectable by MR arthrography. In most cases it is an associated finding of rotator cuff abnormalities and likely to have a similar etiology. When lesions of the anterior rotator cuff are recognized, the biceps tendon should be scrutinized for inflammatory changes.     

MR imaging,MR arthrography,and specimen correlation of the posterolateral corner of the knee: an anatomic study

OBJECTIVE: We sought to evaluate the anatomy of the posterolateral aspect of the knee with anatomic dissection, MR imaging, MR arthrography, and sectional anatomy. MATERIALS AND METHODS: We assessed the posterolateral corner of the knee during dissection of one gross anatomic specimen. MR imaging and MR arthrography were performed in seven additional knee specimens. T1-weighted spin-echo MR images were obtained in the standard imaging planes as well as in the coronal oblique plane. The specimens underwent T1-weighted spin-echo MR imaging after administration of intraarticular contrast material and were sectioned into planes corresponding to those of the MR images. RESULTS: At anatomic dissection, the following posterolateral structures were identified: the arcuate ligament (medial and lateral limbs), fabellofibular ligament, popliteofibular ligament, popliteus tendon and its two posterior attachments to the lateral meniscus, fibular collateral ligament, direct and anterior arms of the tendon of the long head of the biceps femoris muscle, and direct and anterior arms of the tendon of the short head of the biceps femoris muscle. Correlation of MR imaging and anatomic findings showed that the popliteofibular ligament and oblique popliteal ligament were found in 57% and 100% of specimens, respectively. At least one of the two limbs of the arcuate ligament was identified in 71% of specimens. The fabellofibular ligament was not identified on MR images in any of the specimens. The anteroinferior and posterosuperior popliteomeniscal fascicles were identified in all specimens. CONCLUSION: The posterolateral corner of the knee comprises complex and variable anatomic structures. Recognition of these variations is important in the assessment of MR images of the knee.     

MR and CT arthrography of the knee

MR and CT arthrography are important imaging modalities for the assessment of the knee in certain situations. Indications for MR arthrography of the knee include assessment of the postoperative meniscus, the presence of chondral and osteochondral lesions, and the presence of intra-articular bodies. The major indication for CT arthrography is evaluating suspected internal derangement in patients who are unable to undergo MRI. In addition to reviewing the established clinical indications for MR and CT arthrography of the knee, the commonly used techniques, normal variants that can simulate disease, and the most commonly found pathologies that can be diagnosed with these modalities are discussed. Potential indications that are not currently well established in the literature including the evaluation of anterior cruciate ligament injury and autologous chondrocyte implants are examined. Where appropriate, the literature on controversial topics or diagnoses is reviewed. The use of conventional imaging versus CT and MR arthrography is also compared.     

肱二头肌长头腱撕裂的肩关节MRI评价

目的 评价肩关节MRI对肱二头肌长头腱撕裂的诊断价值,并对比分析肩关节MR造影和常规肩关节MRI的诊断性能.方法 由2名影像诊断医师独立回顾分析215例肩关节MR图像,包括107例肩关节MR造影和108例常规肩关节MRI,分析结果与肩关节镜手术相比较.计算MRI评价肱二头肌长头腱撕裂的诊断敏感性、特异性和准确性.采用Kappa分析2名影像诊断医师评价的一致性.结果 215例中,肱二头肌长头腱完伞撕裂7例,部分撕裂29例,无撕裂179例.医师甲用肩关节MRI评估肱二头肌长头腱撕裂(包括完全和部分)的敏感性、特异性和准确性分别为72.2%(26/36)、91.6%(164/179)和88.4%(190/215),医师乙分别为80.6%(29/36)、93.8%(168/179)和91.6%(197/215),2名医师的评估结果间一致性好(Kappa=0.681).肱二头肌长头腱完全撕裂,2名医师的诊断敏感性、特异性和准确性均为100%(7/7)、100%(208/208)和100%(215/215).利用肩关节MR造影评价肱二头肌长头腱撕裂时,医师甲的准确性为93.4%(100/107),医师乙为96.3%(103/107),均明显高于常规肩关节MRI的结果[医师甲为83.3%(90/108),医师乙为87.0%(94/108),P值均<0.05].结论 肩关节MRI是评价肱二头肌长头腱撕裂比较可靠的方法,而且肩关节MR造影的准确性优于常规肩关节MRI.     

The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow

There are no clear guidelines for diagnostic imaging of articular and soft tissue pathologies of the shoulder and elbow. Several methods are used, including magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US). Their cost-effectiveness is still unclear. We performed a meta-analysis of the relevant literature and discussed the role of MR imaging of the shoulder and elbow compared with other diagnostic imaging modalities. For the shoulder impingement syndrome and rotator cuff tears, MRI and US have a comparable accuracy for detection of full-thickness rotator cuff tears. MRA and US might be more accurate for the detection of partial-thickness tears than MRI. Given the large difference in cost of MR and US, ultrasound may be the most cost-effective diagnostic method for identification of full-thickness tears in a specialist hospital setting (Evidence level 3). Both MRA and CT arthrography (CTA) are effective methods for the detection of labrum tears. More recently, multidetector CTA has offered the advantages of thinner slices than with MRA in a shorter examination time. Still, MRA has the advantage towards CTA to directly visualize the affected structures with a better evaluation of extent and location and to detect associated capsuloligamentous injuries. For the elbow pathologies, plain MRI or MRA have the advantage towards CTA to detect occult bone injuries. CTA is better for the assessment of the thin cartilage of the elbow. Both US and MRI are reliable methods to detect chronic epicondylitis; US is more available and far more cost-effective (Evidence level 2). MRA can differentiate complete from partial tears of the medial collateral ligament. US or MRI can detect partial and complete biceps tendon tears and/or bursitis. MRI can provide important diagnostic information in lesions of the ulnar, radial, or median nerve.     

Intracapsular origin of the long head of the biceps tendon

A developmental anomaly of the long head of the biceps tendon was found in a cadaveric shoulder. Findings on arthroscopy, routine MR imaging, and MR arthrography were compared and correlated with results of anatomic dissection. MR arthrography appears to be a very good diagnostic imaging method for depicting this anomaly prior to arthroscopy. Received: 21 October 1998 Revision requested: 23 November 1998 Revision received: 14 December 1998 Accepted: 18 December 1998     

US of the biceps tendon apparatus

High-resolution real-time sonography of the biceps tendon was performed on 80 patients referred for shoulder arthrography. The arthrograms and sonograms were compared at the levels of the biceps tendon groove and distal tendon. Sonography and arthrography were equally successful in facilitating the evaluation of the bony configuration of the biceps tendon groove, but sonography gave a superior image of the biceps tendon within the groove. In 16 patients, biceps tendon sheath effusions or swelling was detected using sonography; 15 of these patients had associated pathologic conditions elsewhere in the joint. Arthrograms did not disclose a biceps tendon or sheath abnormality in any of these patients. We conclude that sonography could be the imaging method of choice in patients with suspected biceps tendon lesions and that the presence of a biceps tendon or sheath abnormality indicates an increased likelihood of abnormalities elsewhere in the joint.     

Medial dislocation of the biceps brachii tendon: appearance at MR imaging

Abnormalities of the long tendon of the biceps brachii muscle commonly accompany other lesions about the shoulder, especially rotator cuff rupture, and are a frequent cause of a painful shoulder. The spectrum of abnormalities associated with medial displacement of the biceps tendon seen at magnetic resonance (MR) imaging was reviewed in six patients. MR imaging was performed on a 1.5-T system with use of a dedicated surface coil. The findings at MR imaging were correlated with those at surgery. Two types of medial displacement of the biceps tendon were identified. More frequently observed was a defect in the subscapularis apparatus that allowed intraarticular entrapment of the biceps tendon. Less commonly observed was incomplete dislocation, with the biceps tendon lying between a partially disrupted subscapularis tendon. MR imaging enabled accurate identification of medial dislocation of the biceps tendon and entrapment of the tendon within the glenohumeral joint. MR imaging also demonstrated the associated disruption of the subscapularis tendon that must be present to allow the biceps tendon access to the joint space.