Shoulder MR arthrography: which patient group benefits most?

OBJECTIVE: We sought to compare the diagnostic accuracy of conventional MRI versus MR arthrography of the shoulder in the assessment of high-performance athletes (professional baseball players) and to compare our findings in these patients with the conventional MRI and MR arthrographic findings in an age-matched control group of nonprofessional athletes. MATERIALS AND METHODS: Conventional MRI and MR arthrographic examinations of the shoulder in 20 consecutive professional baseball players with shoulder pain were reviewed retrospectively by two musculoskeletal radiologists in consensus. These interpretations were compared with retrospective consensus interpretations of conventional MRI and MR arthrographic examinations of the shoulder obtained in a control group of 50 consecutive nonprofessional athletes with shoulder pain. MR images were assessed for full- or partial-thickness supraspinatus tendon tears, superior labral anteroposterior (SLAP) tears, and anterior or posterior labral tears. RESULTS: In the 20 consecutive professional athlete patients, two full-thickness and six partial-thickness undersurface supraspinatus tendon tears were seen on MR arthrography but not seen on conventional MRI as well as six SLAP tears, two anterior labral tears, and one posterior labral tear. Three patients had both SLAP tears and full- or partial-thickness supraspinatus tendon tears. Of 14 patients with findings on MR arthrography that were not seen on MRI, 11 had arthroscopic correlation. In all 11, arthroscopic findings confirmed findings on MR arthrography. In the group of 50 nonprofessional athlete patients, five had additional findings on MR arthrography not seen on conventional MRI: two anterior labral tears, two partial-thickness supraspinatus tendon tears, and two SLAP tears. One patient had both a partial-thickness supraspinatus tendon tear and a SLAP tear seen on MR arthrography. The five patients with additional findings on MR arthrography had arthroscopy. In all five, arthroscopic findings confirmed the findings on MR arthrography. CONCLUSION: MR arthrography is considerably more sensitive for detection of partial-thickness supraspinatus tears and labral tears than conventional MRI. MR arthrography showed injuries in addition to those seen on conventional MRI in 14 of 20 patients in the high-performance athlete group. These results suggest high-performance athletes may be a subgroup of patients for whom MR arthrography yields considerably more diagnostic information than conventional MRI.     

The relationship of superior labralanteroposterior (SLAP) lesions and pseudolaxity to shoulder injuries in the overhead athlete

Understanding the effect of superior labral lesions on the function of the shoulder is essential to successfullytreating the overhead athlete. Recognizing the pseudolaxity owing to superior labral anteroposterior (SLAP) lesions and the pathological "peel-back" sign is critical in evaluating the injured shoulder in general and repairing the SLAP lesion in particular. The mechanical characteristics of suture anchors are more favorable than tacks in resisting the pathological forces responsible for the peel-back mechanism. The higher success rate of arthroscopic suture anchor repair of SLAP lesions in comparison with open capsulolabral reconstruction suggests that SLAP lesions are the usual cause of the "dead arm" syndrome. In our experience, arthroscopic repair of SLAP lesions can return the overhead athlete to their preoperative level of function in the vast majority of cases (87% return to preoperative level for two or more seasons).     

How often do surgeons intervene on shoulder labral lesions detected at MR examination? A retrospective review of MR examinations correlated with arthroscopy

Objective:

We report the prevalence of surgical intervention on shoulder labral lesions detected at MR examinations and how surgeons describe labral tears seen at MR examinations in their arthroscopy reports.

Methods:

A retrospective review of 100 consecutive patients aged 50 years or younger who had shoulder labral tears on MR and went on to have surgery performed. It was determined whether surgical intervention was performed on the MR lesions.

Results:

Of these 100 patients, 72 had superior labral anterior to posterior (SLAP) tears, 38 had posterior labral tears and 28 had anterior labral tears on MR examination. All 100 patients went on to arthroscopy. All lesions described on MRI were described on arthroscopy. Of the 72 SLAP tears, 64 were described as fraying on arthroscopy with 51 debrided. The remaining eight SLAP tears were tacked surgically. Of the 38 posterior labral tears, 36 were described as fraying on arthroscopy with 29 debrided and 2 had surgical tacking performed. Of the 28 anterior labral tears described on MR examination, 26 had surgical tacking performed and 2 were debrided. There were four SLAP tears, two anterior labral tears and three posterior labral tears seen on arthroscopy but not seen on MR examination.

Conclusion:

In this series, a high percentage of SLAP tears and posterior labral tears described on MR examination did not have surgical tacking. Most anterior labral tears had surgical tacking. Based on the above, our surgeons request we describe superior and posterior labral lesions as fraying and/or tearing, unless we can see a displaced tear. Most anterior labral lesions are treated with surgical tacking.

Advances in knowledge:

MRI allows for sensitive detection of labral tears. The tears often are not clinically significant.Labral tears are common injuries that often require surgical intervention. In our practice, we commonly see labral tears on MR examination and report them to surgeons. With modern high-resolution MRI, as well as increased awareness of labral tears by radiologists, labral tears are commonly reported findings on MR examinations. Sensitivities and specificities for detection of labral tears as compared with those from arthroscopy at 3.0 T have been reported as follows: superior labral anterior to posterior (SLAP) tears (90% sensitive and 100% specific), anterior labral tears (89% sensitive and 100% specific) and posterior labral tears (86% sensitivity and 100% specific).¹ Sensitivities of 100% for anterior labral tears, 86% for superior labral tears and 74% for posterior labral tears as compared with those from arthroscopy have been reported using high-resolution 1.5 T conventional MR examinations.²In our practice, we have been told by our surgeons that we describe some SLAP tears and posterior labral tears on MR that they find on arthroscopy to be degenerative fraying. For this reason, we sought to find (1) how often does a surgeon intervene on labral tears and (2) how do surgeons describe labral tears seen at MR examinations in their arthroscopy reports.     

Superior labrum anterior posterior lesions of the shoulder: Operative techniques of management

Since the advent of shoulder arthroscopy, pathology of the superior glenoid labrum and biceps anchor has been increasingly recognized as a source of shoulder pain and disability. Additional biomechanical testing has substantiated the role of the superior labrum and biceps anchor in glenohumeral stability. The diagnosis of superior labral injury such as the superior labrum anterior posterior (SLAP) lesion remains difficult, as the history, clinical examination, and radiographic evaluation can only raise suspicion. The ultimate diagnosis of the SLAP lesion can only be made with a well-directed diagnostic glenohumeral arthroscopy. The treatment of SLAP lesions depends on the type of SLAP lesion encountered at arthroscopy. This includes debridement of most type I and III lesions, and repair of type II and many type IV SLAP lesions. In this report, we will present our basic approach towards evaluation and treatment of SLAP lesions at the Southern California Orthopedic Institute.     

Superior labral anteroposterior lesions of the shoulder: part 1, anatomy and anatomic variants

OBJECTIVE: The objectives of this article are to provide a pictorial review of labral anatomy and physiology, with particular attention to commonly seen anatomic variants and pitfalls, and to present standard imaging techniques and approaches to MRI interpretation to facilitate diagnosis and treatment of superior labral anteroposterior (SLAP) lesions. CONCLUSION: Imaging plays an important role in the diagnosis of SLAP tears. Knowledge of glenolabral anatomy, related structures and variants, proper imaging techniques, and a systematic approach to MRI interpretation is important in the diagnosis and treatment planning of the 10 types of SLAP lesions. Arthroscopy offers a means for definitive diagnosis.     

SLAP tears of the glenoid labrum in contact athletes.

OBJECTIVE: To describe the distribution and clinical presentation of labral injuries in rugby players and the time taken for them to return to sports. DESIGN: Retrospective cohort study. SETTING: Busy shoulder practice in the North West of England, treating a large number of professional athletes. PATIENTS: A review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Eighteen patients had a documented SLAP tear; this group represented our study population. INTERVENTIONS: Arthroscopic debridement and/or stabilization was carried out for all labral injuries using Panaloc anchors and No. 2 PDS via a 2 portal technique. MAIN OUTCOME MEASUREMENTS: Classification of injury, Satisfaction, Time to return to play. RESULTS: The incidence of SLAP tears in our study population was 35%. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%), and 2 SLAP tears associated with an anterior and posterior labral injuries (11%). Of the 18 SLAP tears, 14 (78%) were type 2, 3 (17%) were type 3, and 1 (5%) was type 4. None of the patients with a SLAP tear presented with symptoms of instability. MR Arthrogram had a 76% sensitivity for detecting SLAP tears. By 6 months postsurgery, 89% of patients were satisfied. Patients with isolated SLAP tears were the quickest to return to sports, at an average of 2.6 months postsurgery. CONCLUSIONS: SLAP tears are a common injury in rugby players. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.     

Prevalence of HAGL lesions and associated abnormalities on shoulder MR examination

Objective

Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon shoulder injury. We report the prevalence of HAGL lesions and other associated shoulder injuries in a large series of shoulder MR examinations. All results were correlated with surgery.

Materials and methods

MR reports of 1,000 consecutive conventional shoulder MR exams performed on patients with shoulder pain were reviewed in our information system for the word HAGL. A total of 743 patients went on to surgery. There were 23 HAGL lesions reported at surgery. Those 23 examinations were reviewed retrospectively in consensus by two musculoskeletal radiologists. Scans were assessed for HAGL lesions, full or partial thickness supraspinatus, infraspinatus or subscapularis tendon tears, superior labral anterior posterior (SLAP) tears, anterior or posterior labral tears, and Hill–Sachs lesions.

Results

All 23 patients had HAGL lesions at surgery. Sixteen HAGL lesions were seen on prospective MR reading and 17 HAGL lesions were seen on retrospective MR consensus reading. Six HAGL lesions were not seen on retrospective consensus reading. Sixteen patients had Hill–Sachs deformities, ten had subscapularis tendon tears, five had supraspinatus tendon tears, six had superior labral tearing, and six had anterior labral tears. The above findings were confirmed on arthroscopy.

Conclusions

In this series, there was a 1.6 % prevalence on all MR examinations, and prevalence of 2.1 % seen on MR examination for those who went to surgery. Common injuries associated with HAGL lesions are Hill–Sachs deformities and subscapularis tendon tears. Anterior labral tears were seen in only six cases despite Hill–Sachs deformities in 16 patients. In patients with Hill–Sachs deformities without anterior labral tears, one must carefully assess for the presence of a HAGL lesion.     

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.     

Indirect magnetic resonance arthrography of the shoulder; a reliable diagnostic tool for investigation of suspected labral pathology

Purpose

Indirect magnetic resonance arthrography (I-MRA) confers significant logistical advantages over direct MRA and does not require articular injection. In this study, we determined the diagnostic performance of I-MRA in relation to conventional MRI and arthroscopy or surgery in detecting tears of the glenoid labrum, including Bankart lesions and superior labral antero-posterior (SLAP) tears in a standard clinical setting.

Patients and methods

Ninety-one symptomatic patients underwent conventional MRI and I-MRA of the affected shoulder, followed by either arthroscopy or open surgery. The scans were interpreted independently by two experienced radiology consultants with a special interest in musculoskeletal radiology. Using the surgical findings as the standard of reference, sensitivity, specificity, and diagnostic accuracy of conventional non-contrast MRI and I-MRA in the detection of labral tears were calculated.

Results

The sensitivity of I-MRA was 95 and 97 %, respectively, for two radiologists as opposed to 79 and 83 % for conventional MRI. For both radiologists, the specificity of I-MRA, as well as MRI, was 91 % for detection of labral tears of all types. Accuracy of diagnosis was 93 and 95 %, respectively, for two radiologists with indirect MRA, compared to 84 and 86 % with non-contrast MRI.

Conclusions

This retrospective study shows that I-MRA is a highly accurate and sensitive method for the detection of labral tears. The data obtained supports the use of I-MRA as standard practice in patients with shoulder instability due to suspected labral pathology where further investigative imaging is indicated.     

Magnetic resonance imaging of the long head of the biceps tendon: benefit of coplanar image

PURPOSE: To evaluate coplanar imaging of the long head of the biceps tendon. METHODS: We retrospectively compared coronal oblique magnetic resonance images aligned with the principal supraspinatus tendon and with the intra-articular biceps tendon in 21 patients. Magnetic resonance images were analyzed for lesions depicted, including superior labral anteroposterior (SLAP) tears. Arthroscopic findings were reviewed. RESULTS: Coronal oblique images aligned with intra-articular biceps tendon depicted 18 (86%) of 21 coplanar intra-articular biceps tendons. Coplanar images identified 6 cases of tendinosis, 1 tear, 3 intra-articular ruptures, and 20 (95.2%) of 21 exact origins of the tendon. Arthroscopy revealed 18 SLAP tears. The detection of SLAP lesions between both coronal oblique magnetic resonance images was significantly different (P = 0.007). CONCLUSION: Advantages included imaging of the intra-articular biceps tendon with least partial-volume effects, definition of SLAP lesions and the tendinous origin at the supraglenoid tubercle, depiction of intra-articular bicipital ruptures, and increased sensitivity and specificity for intra-articular lesions.     

The MR arthrographic anatomy of the biceps labral insertion and its morphological significance with labral tears in patients with shoulder instability

Introduction

Most of the fibres of the long head of biceps tendon attach on the superior labrum just posterior to the supraglenoid tubercle.

Aim

Our hypothesis was that posteriorly attached biceps tendons predispose to posterior superior labral tears and SLAP lesions.

Methods and materials

A prospective analysis of all MR shoulder arthrograms for shoulder instability referred from the shoulder specialist clinics, performed during a one year period were reviewed by two independent observers who were blinded to clinical history. The biceps attachment was classified into four groups according to the method described in an earlier cadaveric study into four groups; posterior-type 1, predominantly posterior-type 2, equal contributions to both anterior and posterior labrum-type 3 and predominantly anterior labral attachment-type 4. Data was analysed using Kappa statistics and Fischer's exact test.

Results

48 patients (33 males and 15 females) were included in this study with a mean age of 32 years. Majority, 22 patients (46%) had a type 1 attachment of the biceps on the superior labrum. There was moderate intra-observer and good interobserver agreement with a Kappa of 0.58 and 0.63 respectively. There was a significant association between a type 2 attachment and posterior tears (p ≤ 0.04) and also between a type 2 attachment and SLAP tears (p ≤ 0.04).

Conclusion

Our results suggest that variation in anatomy of biceps origin influences the type of labral tears that occur in patients with shoulder instability. The importance of these findings could influence selection of individuals in throwing sports like cricket and baseball.     

Superior labral anteroposterior lesions of the shoulder: part 2, mechanisms and classification

OBJECTIVE: The objectives of this article are to discuss the 10 distinct patterns of superior labral anteroposterior (SLAP) tears to facilitate adequate diagnosis and treatment. Correlations with clinical presentation, mechanism of injury, and treatment will enhance understanding. CONCLUSION: Imaging plays an important role in the diagnosis of SLAP tears. Knowledge of glenolabral anatomy, related structures and variants, proper imaging techniques, and a systematic approach to MRI interpretation is important in the diagnosis and treatment planning of the 10 types of SLAP lesions. Arthroscopy offers a means for definitive diagnosis.     

Arthroscopic assessment of the unstable shoulder

The purpose of this study was to evaluate prospectively the findings during shoulder arthroscopy in patients with recurrent anterior instability of the gleno-humeral joint. One hundred and seventy-eight patietns who fulfilled the criteria of having had at least one documented shoulder dislocation were included in the study. The pathological findings most frequently noted at arthroscopy were: anterior glenoid labral tears (85%), ventral capsule insufficiency (80%), Hill-Sachs compression fractures (67%), glenohumeral ligament insufficiency (55%), rotator cuff tears (20%), posterior glenoid labral tears (8%), and SLAP lesions (5%). Abnormalities were noted more frequently than expected, and there were significant differences between preoperative and postoperative diagnoses. Our study has taught us that a mulitplicity of morphological changes are associated with instability of the glenohumeral joint, and that there is no single cause. The labrum and rim of the anterior inferior glenoid, for instance, showed typical abnormalities corresponding to different entities of anterior instability. In practice, this is very important, as the abnormalities visualized by imaging methods determine the surgical treatment.     

Bizepsprobleme: Ultraschall, Magnetresonanztomographie und MR-Arthrographie

Ultrasound and MR imaging are competitive imaging modalities for the diagnosis of pathologic conditions of the biceps tendon. MR imaging has substantial advantages over ultrasound because biceps tendon lesions are most commonly located in the proximal part where lesions are hidden under the acromion for ultrasound assessment. The value of MR arthrography is substantiated by the capability to assess associated diagnoses which are otherwise difficult to assess. Associated diagnoses include full- and partial thickness tears of supraspinatus and subscapularis tendons, pulley lesions, and adhesive capsulitis (frozen shoulder). Moreover, MR arthrography is the method of choice for the assessment of superior labral anterior posterior (SLAP) lesions.     

Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis

PURPOSE: To determine the reliability and accuracy of magnetic resonance (MR) arthrography for the diagnosis of superior labral anterior posterior (SLAP) tears. MATERIALS AND METHODS: The MR arthrograms in 80 patients who underwent arthroscopy and MR arthrography during a 54-month period were retrospectively reviewed. MR arthrograms were independently scored by three observers for the presence and type of SLAP lesion. Type I SLAP lesions were regarded as negative as they most often are not clinically relevant. Interobserver agreement for detection of SLAP lesions was calculated by using kappa coefficients. The differences in areas under the receiver operating characteristic (ROC) curves were assessed with a univariate z score test. RESULTS: At arthroscopy, there were 25 SLAP tears: type II (n = 22), type III (n = 2), and type IV (n = 1). Sensitivity, specificity, and accuracy of each reader were 92%, 84%, and 86%; 92%, 82%, and 85%; and 84%, 69%, and 74%, respectively. Interobserver agreement for SLAP tears was substantial (kappa = 0.77) to moderate (kappa = 0.52, kappa = 0.44). The areas under the ROC curves for each reader were 0.94, 0.93, and 0.83, which were not significantly different. CONCLUSION: MR arthrography of the shoulder is reliable and accurate for detection of SLAP tears.     

Can isotropic fast gradient echo imaging be substituted for conventional T1 weighted sequences in shoulder MR arthrography at 3 Tesla?

PURPOSE: To assess the practical utility of isotropic shoulder imaging in patients undergoing MR arthrography. Isotropic shoulder imaging can be performed in less than three minutes with use of fast gradients. MATERIALS AND METHODS: Two experienced musculoskeletal radiologists retrospectively interpreted MR images of the shoulder in 100 consecutive patients undergoing MR arthrography of the shoulder. All patients underwent MRI of the shoulder in oblique coronal, oblique sagittal, and axial planes on a 3.0-Tesla MRI system. All patients had conventional fast spin-echo T1-weighted imaging. All patients also had thin section (0.4 mm) isotropic spoiled gradient echo images performed. A total of 67 of the 100 patients underwent subsequent arthroscopy and results were compared with MR interpretations. RESULTS: There were 41 full-thickness supraspinatus tendon tears, nine partial-thickness supraspinatus tendon tears (seven articular surface and two bursal surface), 21 superior labral, 18 anterior labral, and seven posterior labral tears demonstrated by consensus retrospective reading of the 100 shoulder MR exams. There was no difference in interpretation of the isotropic images as compared to the conventionally acquired images in the oblique coronal, oblique sagittal, and axial planes. Some patients had more than one finding on each exam. A total of 67 patients went on to arthroscopy. There were 41 full-thickness supraspinatus tendon tears, nine partial-thickness supraspinatus tendon tears, 21 superior labral, 18 anterior labral, and seven posterior labral tears demonstrated on arthroscopy. All full- and partial-thickness supraspinatus tendon tears seen at arthroscopy were seen on consensus MR reading. A total of 19 out of the 21 patients with superior labral anterior posterior (SLAP) tears at arthroscopy were seen on consensus MR reading. A total of 16 of the 18 anterior labral tears and six of the seven posterior labral tears seen at arthroscopy were seen on consensus MR reading. Some of the 67 patients had more than one finding on arthroscopy. CONCLUSION: Isotropic imaging of the shoulder is practical in clinical imaging when performed with use of fast gradients on a 3-Tesla system. Isotropic imaging provides the same clinical information as conventional imaging and can be acquired in less than three minutes.     

Shoulder instability: impact of glenohumeral arthrotomography on treatment

We used arthrotomography to study the glenoid labrum in 114 patients. Sixty-nine of the patients had anatomic instability of the shoulder (including recurrent dislocation and subluxation of the shoulder), and 45 patients had functional instability of the shoulder (denoted by chronic pain, clicking of the joint, and the sensation that an unstable condition exists without the objective signs of it). Labral tears were revealed arthrotomographically in 86% of the patients with anatomic instability, while only 40% of the patients with functional instability had labral abnormalities, and these were primarily of minor severity. Fifty-six patients (44 of whom had anatomic instability; 12, functional instability) required surgery. The surgical findings were correlated with the arthrotomographic findings, and no false-positive results were revealed. However, arthrotomography demonstrated only part of the pathologic condition of two patients. These results confirm that there is a strong correlation between labral pathologic conditions and anatomic instability of the shoulder. Arthrotomographic studies have a great impact on the selection of therapy in cases of both anatomic and functional instability of the shoulder.     

High-field and low-field MR imaging of superior glenoid labral tears and associated tendon injuries

OBJECTIVE: The purpose of this study was to determine the performance characteristics of high-field and low-field MR imaging for the diagnosis of a glenoid superior labral anteroposterior (SLAP) tear. MATERIALS AND METHODS: High-field (n = 46) or low-field (n = 21) MR imaging was performed on 41 patients with SLAP tears and 26 patients with normal superior labra. The superior labrum was classified into one of four types on the basis of patterns of intralabral signal intensity. The relative frequency of rotator cuff tears and long head of the biceps tendinopathy was also assessed. RESULTS: For the diagnosis of SLAP tear, the sensitivity of high-field MR imaging was 90% (95% confidence interval = 74%, 98%), specificity was 63% (35%, 85%), and accuracy was 80% (66%, 91%). The sensitivity of low-field MR imaging was 64% (31%, 89%), specificity was 70% (35%, 93%), and accuracy was 67% (43%, 85%). A branched linear or stellate focus of abnormal intralabral signal intensity was associated with a SLAP tear in 86% of patients. Conversely, two other labral patterns correlated with a normal superior labrum in 71% of patients. Abnormal signal intensity in the biceps tendon was seen in 15% of patients with a SLAP tear. Full-thickness (37%) and partial-thickness (31%) rotator cuff tears were often seen. CONCLUSION: The performance characteristics of high-field MR imaging are superior to those of low-field MR imaging for the diagnosis of a superior labral tear. Rotator cuff tears can be seen in many patients with superior labral tears, but abnormal signal intensity in the biceps tendon is uncommon.