The painful shoulder: MR imaging of the glenohumeral joint

We used magnetic resonance imaging in 41 patients with shoulder pain. Magnetic resonance was found useful in depicting the spectrum of rotator cuff abnormalities associated with mechanical impingement including both large and small rotator cuff tears as well as tendinitis. Abnormalities of the capsular mechanism, osseous tumors, osteonecrosis, and injuries to the supporting musculature are also well depicted.     

MR arthrography of the glenohumeral joint: modified posterior approach without imaging guidance

Institutional review board approval and informed consent were obtained. The purpose of the study was to prospectively perform magnetic resonance (MR) arthrography of the glenohumeral joint by using modified posterior approach without ultrasonographic or fluoroscopic guidance. A solution containing 0.1 mL of gadolinium chelate, 15 mL of saline, and 5 mL of 2% lidocaine was subsequently injected into the glenohumeral joint in 147 patients (81 men, 66 women; age range, 20-79 years). A 21-gauge needle was advanced along a trajectory connecting a skin mark 3-4 cm below and 2 cm medially to the posterolateral margin of the acromion and the coracoid process, as assessed with palpation, proceeding in posteroanterior direction. The joint was successfully entered at first attempt in 125 (85%) patients, at second attempt in 19 (13%), and at third attempt in three (2%). Contrast material-enhanced images were evaluated for presence, site, and maximal extent of contrast material extravasation; route of diffusion of the extravasation; compromised or noncompromised diagnostic quality; and presence of gas bubbles. Extravasation occurred in seven patients: at the interval between the teres minor muscle and infraspinatus muscle in five and within the infraspinatus muscle belly in two; extravasation had diffused along the teres minor muscle and infraspinatus muscle in five (71%) and along the teres minor muscle in two (29%). The mean extension of extravasation was 15 mm. Image quality was not compromised, and no gas bubbles were detected. The procedure was successful in all patients, with no complications.     

Distribution of normal and abnormal fluid collections in the glenohumeral joint: Implications for MR arthrography

Although magnetic resonance (MR) images of the glenohumeral joint frequently demonstrate intraarticular fluid, no specific criteria have, to the authors' knowledge, been published that allow accurate assessment of the amount of fluid present. Also, despite the increasing use of MR arthrography of the shoulder, the optimal amount of intra-articular fluid that should be used with this technique has not been determined. The authors progressively distended the glenohumeral joint in six cadaveric shoulder specimens with a dilute gadopentetate dimeglumine solution and obtained MR images after injection of 2, 5, 10, 15, and 20 mL of the solution. The pattern of fluid distribution was evaluated, and these results were then used to estimate the amount of fluid that was present in the glenohumeral joint on MR images of 20 shoulders obtained in 12 asymptomatic volunteers. In 14 of these shoulders, intraarticular fluid was present; however, in none was more than 2 mL evident. Results of the cadaveric study also indicated that 15 mL of intraarticular fluid appears to be the optimal amount for MR arthrography.     

Comparison of supraspinatus tendon and glenohumeral joint axes in MR imaging of the shoulder

Objective. In magnetic resonance (MR) imaging of the shoulder, oblique coronal images are used for evaluating the supraspinatus tendon (SST) of patients with suspected rotator cuff tear or impingement. This study aimed to compare orientation of the SST long axis with planes perpendicular to the glenohumeral joint (GHJ). Design and patients. The axial scans of 100 consecutive patients referred for MR imaging or MR arthrography of the shoulder were reviewed. Using the electronic cursors of a computer workstation, the angle of the SST long axis was measured and compared with the angle obtained through the GHJ utilizing three different landmarks: perpendicular to the joint (GHJ-90), joint–humeral head center axis (GHJ-H) and joint–scapular body axis (GHJ-S). Results. Differences in angulation between axes of the SST and the three GHJ axes averaged only about 5° [range of means 4.5–5.3°, range of standard deviation (SD) 3.8–4.6°]. In the majority of shoulders, angular differences measured 4 or less for all SST/GHJ comparisons. Similarly, small angular differences in the three GHJ axes were found: 4.5° (SD 3.3°) for GHJ-90/GHJ-S, 5.0° (SD 4.0°) for GHJ-S/GHJ-H and 2.9° (SD 3.0°) for GHJ-90/GHJ-H. Correlation between the GHJ-90 and GHJ-H axes was particularly good, with differences of 4° or less in 84% of shoulders. The orientations of the GHJ axes and that of the SST long axis are comparable. Conclusion. The GHJ may potentially be used as a landmark for obtaining oblique coronal images of the SST. Received: 19 November 1999 Revision requested: 18 January 2000 Revision received: 27 March 2000 Accepted: 5 April 2000     

MR imaging of the glenohumeral ligaments

The glenohumeral ligaments, particularly the inferior one, are the major passive stabilizers of the joint, and the labrum functions as a site of ligamentous attachment.The strong union between the collagen fibers of the glenohumeral ligaments and the glenoid labrum is more resistant to injury than the union between the glenoid rim and the labrum. Labral tears associated with glenohumeral instability are therefore usually secondary to avulsion rather than impaction. This article reviews the normal MR imaging anatomy, variants and pitfalls of the glenohumeral ligaments, and the basic biomechanics of the glenohumeral ligaments. Examples of injuries involving these structures are provided.     

Non-contrast MR imaging of the glenohumeral joint. Part I. Normal anatomy

MR imaging of the shoulder without contrast is frequently used for evaluation of glenohumeral instability in spite of the popularity of MR arthrography. With proper imaging technique, familiarity with normal anatomy and variants as well as knowledge of the expected pathologic findings high diagnostic accuracy may be achieved.     

MR imaging in sports-related glenohumeral instability

Sports-related shoulder pain and injuries represent a common problem. In this context, glenohumeral instability is currently believed to play a central role either as a recognized or as an unrecognized condition. Shoulder instabilities can roughly be divided into traumatic, atraumatic, and microtraumatic glenohumeral instabilities. In athletes, atraumatic and microtraumatic instabilities can lead to secondary impingement syndromes and chronic damage to intraarticular structures. Magnetic resonance (MR) arthrography is superior to conventional MR imaging in the diagnosis of labro-ligamentous injuries, intrinsic impingement, and SLAP (superior labral anteroposterior) lesions, and thus represents the most informative imaging modality in the overall assessment of glenohumeral instability. This article reviews the imaging criteria for the detection and classification of instability-related injuries in athletes with special emphasis on the influence of MR findings on therapeutic decisions.     

Magnetic resonance imaging of glenohumeral joint instability

Shoulder instability is common, especially anterior subluxation and dislocation. The sequelae are well seen on magnetic resonance imaging and include tears of the labrum, glenohumeral ligaments, capsule, tendons, and muscles. This article seeks to discuss and illustrate common pitfalls and lesions associated with instability. Anatomic and technical considerations, including the use of magnetic resonance arthrography, are also addressed.     

MR arthrography of the posterior labrocapsular complex: relationship with glenohumeral joint alignment and clinical posterior instability

OBJECTIVE: The purpose of our study was to investigate the relationship between tears of the posterior labrocapsular complex and glenohumeral alignment on MR arthrography and the presence and extent of posterior labrocapsular tears in patients with posterior instability. MATERIALS AND METHODS: Posterior labrocapsular tears identified on 24 MR arthrograms and surgically confirmed were evaluated for length of tear and labrocapsular avulsion. These examinations and a comparison cohort of 70 normal MR arthrograms with normal findings were also evaluated for humeral head position relative to the glenoid fossa. Medical records were reviewed for clinical diagnosis of posterior instability and history of shoulder trauma. RESULTS: The position of the humeral head relative to the glenoid was significantly more posterior in patients with posterior labral tear than in patients with a normal posterior labrum (4.9 mm versus 0.7 mm; p < 0.0001). The mean length (+/- SD) of posterior labral tear was 15.9 +/- 1.7 mm, and a direct correlation was found between tear length and posterior humeral translation (r = -0.65; p = 0.002). Posterior labral tears were significantly longer (18.6 vs 13.1 mm; p = 0.04), and posterior humeral translation was greater (6.4 vs 3.4 mm; p = 0.006) in patients with labrocapsular avulsion than in those without avulsion. Twelve (50%) of the patients with posterior labrocapsular tear had posterior instability, and 10 (83%) had a history of macrotrauma. On MR arthrography, the mean posterior humeral translation was greater (6.2 mm +/- 0.08; p = 0.019), posterior labral tears were longer (19.4 mm +/- 1.7; p = 0.0008), and labrocapsular avulsion was more common (83%; p = 0.0001) in patients with posterior instability than in patients who had a posterior labral tear but a clinically stable shoulder. CONCLUSION: Clinical posterior instability is associated with excessive posterior humeral translation, long posterior labral tears, and posterior labrocapsular avulsion.     

Magnetic resonance imaging of glenohumeral joint diseases

Through the application of oblique planes and flexible surface coil techniques, magnetic resonance imaging (MRI) promises to be of great clinical value in the evaluation of a variety of pathologic conditions affecting the shoulder. In patients with joint effusions, the tendinous portion of the rotator cuff, glenoid labrum, and bicipital tendon can be readily visualized. This capability has particular relevance in patients with inflammatory disease and traumatic conditions. Rotator cuff atrophy and impingement of the coracoacromial arc upon the supraspinatus muscle and tendon can also be demonstrated. MRI is also useful in the evaluation of shoulder instability.     

Non-contrast MR imaging of the glenohumeral joint. Part II. Glenohumeral instability and labrum tears

MR imaging of the shoulder without contrast is frequently used for evaluation of glenohumeral instability in spite of the popularity of MR arthrography. With proper imaging technique, familiarity with normal anatomy and variants as well as knowledge of the expected pathologic findings high diagnostic accuracy may be achieved.Part I of this Review Article Non-contrast MR imaging of the glenohumeral joint: Normal anatomy appeared in the previous issue (Number 10/Oct. 2004). See also:     

Optimizing joint imaging: MR imaging techniques

For optimizing MR of the joints, a sophisticated knowledge of MR system hard-and software condition, and coil technologies, sequence and contrast preparation techniques, and the use of paramagnetic contrast agents is necessary. This review article discusses the basic principles of the appropriate use of surfacecoilsas well as the different conventional and fast imagingsequences, including three-dimensional (3D)MR imaging. In addition, the applications of contrast agents as well as the most important contrast prepaation techniques are reviewed.     

MR arthrography of the glenohumeral joint: a tailored approach.

OBJECTIVE: The purpose of this study was to anatomically confirm that anterior shoulder injection could result in penetration of the anterior stabilizing structures of the glenohumeral joint and to advocate the use of a tailored approach to MR arthrography based on presenting symptoms. CONCLUSION: A tailored approach to MR arthrography may be a useful way to isolate expected pathology in the shoulder and limit confounding findings related to the performance of the procedure.     

Pisotriquetral joint: assessment with MR imaging and MR arthrography

PURPOSE: To evaluate magnetic resonance (MR) imaging and MR arthrographic findings in the pisotriquetral joint (PTJ) and their contribution to assessment of PTJ osteoarthritis. MATERIALS AND METHODS: Images of 22 fresh human cadaveric PTJs were obtained with both conventional and arthrographic MR techniques. The MR appearances of all intraarticular and periarticular structures were analyzed and correlated with anatomic slices. Two readers graded visibility of anatomic structures and severity of joint abnormalities. Differences in the visibility ratings at standard MR imaging and at MR arthrography were calculated. Association between the type of pisiform insertion of ligament or muscle with cartilaginous abnormalities of the PTJ was assessed. The association between cartilaginous lesions and osteoarthritic changes was calculated. RESULTS: The tendon sheath, the fibrous capsule, and cartilaginous surfaces were better visualized at MR arthrography than at MR imaging. Pisohamate and pisometacarpal ligaments were slightly better seen on MR arthrograms. Tendons, muscles, and retinacular structures were well demonstrated at both conventional MR and MR arthrography. Cartilaginous lesions and osteophytes were easily identified and were detected more often in the pisiform bone than in the triquetral bone. Communication of the PTJ with the radiocarpal joint was noted in 18 (82%) of 22 wrists. CONCLUSION: MR imaging and/or MR arthrography allows visualization of all anatomic structures of the PTJ. MR arthrography improves visualization of findings of osteoarthritis.