MRI of the rotator

cuff
Functional
considerations
• The muscles of the rotator
cuff resist the upwards force
of the deltoid muscle by
depressing the humeral head.
Functional
considerations
• The muscles of the rotator
cuff compress the humeral
head against the glenoid
cavity, increasing joint
stability
Anatomic
considerations
• Any process that narrows the
subacromial space may affect
the rotator cuff
Anatomic
considerations
• Any process that narrows the
subcoracoid space may affect
the rotator cuff
Pathological
considerations
• Exagerated tensile forces
leads to failure at:
– Musculotendinous junction
– Tendon insertion to bone
– In bone
Pathological
considerations
• In presence of tendon
degeneration excessive
tensile forces may lead to
failure within the tendon itself
Pathological
considerations
• In certain positions eg.
Adduction, the avascular
region is made larger
Pathological
considerations
• Cuff degeneration is
associated with aging
• Pathology is fibrovascular
proliferation and
disorganisation with no
inflammation
• Not a tendonitis – tendonosis
or tendonopathy
Pathological
considerations
• Cuff degeneration is
associated with aging
• Pathology is fibrovascular
proliferation and
disorganisation with no
inflammation
• Not a tendonitis – tendonosis
or tendonopathy
Classification of tears
• Massive tear : Full thickness
tear involving more than one
tendon
• Articular side
• Bursal side
• Intrasubstance
• Low grade < 50% thickness
• Medium grade 50%
• High grade > 50%
Classification of tears
• Retraction
• Presence or absence of
muscle atrophy
– From muscle disuse related to
tear
– Tendon retraction with nerve
injury
• Irregularity of the tendon
• Articular fluid
• Bursal fluid
Classification of tears
• Retraction
• Presence or absence of
muscle atrophy
– From muscle disuse related to
tear
– Tendon retraction with nerve
injury
• Irregularity of the tendon
• Articular fluid
• Bursal fluid
Classification of tears
• Direction of tear
– Vertical
– Oblique
– Horizontal
MR arthrography
• Standard MR inconclusive
• Post op cases
• Special circumstances
– Posterior superior impingement
– Rotator interval lesions
Cuff tears : special
considerations
• Rim – rent tears
– With aging the inner fibres of
the tendon peel away from the
greater tuberosity
– Less common than critical zone
tears
– Young > old
Cuff tears : special
considerations
• Intramuscular ganglia
• Rotator interval tears
• Musculotendinous tears
• Laminated tears
• Greater tuberosity fractures
– If > 5mm displacement assoc.
With cuff tear, my require ORIF
Cuff tears : special
considerations
• Lesser tuberosity fractures
Treatment
• Non operative
– Modification of activity
– Exercises to strentghen muscles
• Operative
– Open or arthroscopic
– Rotator cuff repair
– Subacromial decompression
Treatment
• Acromioplasty
– Resect and smooth
undersurface of acromion
– Resect coraco-acromial
ligament
– When needed, remove AC joint
osteophytes, distal clavicle
Treatment
• Repair torn tendon
– Advance cuff tendons
– Place and tighten tendon
sutures
– Screws used to reinforce repair
– Arthroscopic repair
Impingement
• External
– Subacromial or Subcoracoid
• Tendon degeneration
• Abnormality coracoacromial arch
– Altered acromial shape
– ACJ OA
– CAL thick
– Os acromiale
– GHJ instability
Impingement
• Alteration acromial
morphology
– Degree lateral slope: <or> 10
degrees
– Shape in saittal plane
• 1=straight
• 2=curved
• 3=angular
Impingement
• Alteration coracoid
morphology
– Large or laterally placed
– Decrease coracohumeral
distance
Impingement
• Internal impingement
– Posterosuperior
• Impingement of undersurface of
the cuff on the posterosuperior
part of glenoid
– Anterosuperior
• Impingement of BT,CAL,SGHL and
anterosuperior labrum
• Associated SLAP lesion and
supraspinatus tears