0:00

The history we are given is a 52 year old male with a right shoulder pain,

0:05

limited range of motion for about three months, no injury, no surgery,

0:10

just, uh, starting as I did, uh, previously, uh,

0:14

on earlier weeks. Uh, my checklist for a knee, uh,

0:19

I'm not sure if I, I've gone through, uh, my checklist for a shoulder. But, uh,

0:24

since we're starting, uh, more shoulder cases or, or all shoulder cases today,

0:29

uh, briefly talk about, uh, I've been asked what my checklist is,

0:33

but it's pretty much, uh, similar to what you guys are, are turning in and, and,

0:37

and, uh, the course has provided us templates. But I like to start out,

0:42

uh, and sorry, I, I like to hang Myrons, um, up top,

0:47

followed by Sagittals at the, uh, bottom left and an axial fluid sensitive,

0:51

typically on the bottom right. And these are,

0:54

these four sequences are typically my main workhorses where I work at. In, uh,

0:59

at UCSD, we usually grab about six sequences. We add a, uh,

1:04

sagittal T one typically, and an axial, uh, proton density or, or some other,

1:09

uh, uh, anatomic sequence along with the, um, top two, uh, uh,

1:14

uh, coronal sequences, uh, an anatomic and a fluid sensitive, uh,

1:18

fat suppressed sequence. So, starting with my checklist, I do the cuff tendons.

1:22

So I start with the supraspinatus infraspinatus subscapularis and te minor

1:26

tendons. And you use a combination of, obviously, the C coronals, uh, for,

1:31

especially for the sat, so the supraspinatus and infraspinatus, and the, um,

1:36

the, uh, sagittals for those, uh, two tendons.

1:39

Then I'll glance quickly at the IES minor tendon,

1:42

which is typically gonna be normal in, in most cases,

1:45

you can get some hypertrophy of the muscles typ, uh,

1:47

especially when you have massive rotator cuff tendon tears as the tes minors

1:51

compensating for those torn tendons. And along those lines, uh,

1:55

with the sagittal, I'll also glance at the, the, uh,

1:58

subscapularis tendon kind of scrolling back and forth, forth.

2:02

And as we can see in a bit, what we see this sort of, uh, uh,

2:06

tear of the upper tendon is fibers tracking, uh, medially and, and, uh,

2:10

a little bit of a delaminating type tear there,

2:13

extending towards the Mount Tendus junction, these subscapularis.

2:15

But we'll get to that in a bit. Uh, then I rounded out the, the subscapularis.

2:20

I look at it also in the, in the axial view. Okay, next,

2:24

on my checklist for the shoulder is gonna be the long,

2:26

a long head of the bicep tendon,

2:28

which I'll abbreviate sometimes today as the LHPT, just, uh, for,

2:33

uh, conciseness and for, uh, uh, brevity and speed.

2:37

But as we can see here, this long on the biceps tendon,

2:40

or LHPT is not situated normally in its groove.

2:43

The intertubular groove right here, it's actually, uh, residing,

2:48

uh, intraarticular through this, uh, partial tear, uh,

2:53

of the, particularly of the upper portion of the subscapular tendon.

2:56

And we'll get into more of that in a bit.

2:58

You could also notice here that it's tend nautic at, uh,

3:02

at its dislocated portion within the, uh, intraarticular here as well. Next,

3:07

I'll look at the glenohumeral joint alignment. And along with that,

3:10

I'll look at the labrum and the cartilage.

3:12

What I'm looking for is any decentering. Um,

3:15

especially with rotator cuff tendon tears, we know we lose that vector force,

3:19

and we get that, uh,

3:21

superior migration of the humeral head and narrowing of the acromial humeral

3:25

distance. Sometimes we get, even post,

3:27

some post a slight posterior translation of the, uh,

3:30

humeral head relative to the glenoid as well. Now, we're not, I, in my opinion,

3:34

we're not very accurate for a cartilage, uh, especially for spherical surfaces,

3:39

uh, namely the humeral head and the, uh, femoral head and the hip.

3:43

But we'll still give it a shot. Um, depending on who you read,

3:47

the accuracy can be anywheres from, you know, 60 to high nineties. Uh, but in,

3:52

in my hands, I just feel, and on certain magnets, uh, just not, uh,

3:57

that accurate I find. But I will try to look for it.

4:00

And I try to look for indirect signs, subconscious cyst formation,

4:04

indicating that there may be some, uh,

4:06

high grade conal loss at either the humeral head or glenoid surface. Next,

4:10

I'll look at the AC joint, um, and I'll comment, uh, if there's,

4:15

you know, mild, moderate, or severe, uh, osteoarthrosis. But, uh, uh,

4:20

what I find, uh, and what my mentors and colleagues,

4:23

what we find here at UCSD is, uh, MRI tends to overestimate ahr,

4:28

uhr, clavicular joint osteoarthrosis. Um, so if we have a nice radiograph,

4:33

we'll correlate with that as well. Um, and along these lines,

4:37

using the sagittal, uh, I'll go a couple clicks just lateral to the AC joint,

4:42

and I'll look at the morphology of the, uh, distal chromium,

4:46

whether it is a type one through four, and using my hand, uh,

4:50

I don't know if you guys can see me on the video, but type one is gonna be flat.

4:54

Type two is gonna be a slight curve. Type three is gonna be a hook,

4:58

and that's gonna lead to, uh, external impingement or extrinsic impingement.

5:02

And then type four is reversed, where, um, you basically have the,

5:06

the distal chromium, the, it's convex, uh, downward. Uh,

5:10

but that can also lead to in theory, impingement as well. And along those lines,

5:15

I also look for, uh, uh, an os acromial,

5:17

which can also lead or con contribute to external, uh, uh,

5:22

or extrinsic impingement upon the cuff tendons, uh, as all part of that,

5:27

uh, cortical acromial a that can lead to external impingement. And then, uh,

5:31

finally, I'll look at the muscles for any edema, any atrophy,

5:35

especially for rotator cuff tendons. And finally, I'll look at the, uh,

5:38

muscles and, or, sorry, the, uh, bone morphology and marrow signal. Okay.

5:42

And I'll wrap that up, uh, finally with the, with the axial sequence. All right.

5:48

So, uh, going to this case, uh, jumping right into the meat, we can see,

5:53

okay.

5:53

And I like to start far anteriorly just to pick up that anterior leading edge of

5:57

the supraspinatus. And some of you, uh, have called this, uh, tear, uh,

6:02

accurately so of the supraspinatus. But the main finding here is,

6:06

notice here how the biceps tendon is not diving or running towards the

6:10

pulley mechanism that is comprised of the cortical humeral.

6:13

And the superior glen humeral ligament is just complex.

6:16

As it dies more laterally into the intra particular groove and correlating with

6:20

our axial sequences, we can see, okay,

6:23

that something should be running within this groove,

6:27

the intra particular groove between the luster and greater tuberosities. But we,

6:30

what we see here instead is maybe some, uh, some lining of the, uh,

6:35

the, uh, teno synovium here, but it's basically empty. Okay?

6:40

And where do we, where do we find it? You wanna look at various locations.

6:44

Sometimes it's either gonna be torn or dislocated intraarticular,

6:48

and can also be dislocated,

6:49

extra articular right here as well out out in this, uh, uh,

6:54

area right here.

6:55

So here we have an intraarticular dislocation due to a high grade

7:00

or so, what some people would call the full thickness, uh,

7:03

sort of articular sided tear or intrasubstance tear of the subscapularis,

7:07

allowing dislocation,

7:09

intraarticular of that long head of the biceps tendon,

7:12

which is also likely partially torn,

7:14

as we can see some high fluid signal within, uh,

7:18

within the biceps tendon itself,

7:20

at and near its biceps labral, uh, origin at the supra glenoid, uh,

7:25

tubercle. Okay. So that is the, uh,

7:28

main finding of this case.

7:32

And I'll pause for a moment to see if anyone has any questions on this case.

7:36

There is, I will add, uh, if you guys, uh, uh,

7:39

for those that like to review the literature, you may run across, uh,

7:42

habe Meier classification. That is H-A-B-E-M-E-Y-E-R,

7:48

I believe, if I pronounced it correctly. This is, uh, was described in, uh,

7:52

the journal radiology, the Green Journal back in the,

7:55

I think the nineties or two thousands by Dr. Resnick.

7:58

And basically it's divided into six types.

8:00

But basically this would be fall into, uh, arguably, in my opinion,

8:04

maybe a type three or four where you have the, uh,

8:08

subscapularis tendon tear allowing, uh, that a portion of that,

8:13

uh, longhead biceps tendon to, uh, dislocate intraarticular.

8:18

And if you guys are performing ultrasounds of these

8:23

tendons of shoulders, uh,

8:26

that's one thing to look for is slide your ultrasound probe,

8:31

but more immediately, and sometimes you pick up this, uh, dislocated tendon,

8:36

but just, this is just a nice case of a, of a subscap tendon tear with, uh,

8:41

tearing as well of the supraspinatus. But the main finding, as I mentioned this,

8:45

longhead the biceps tendon is, uh, dislocated, uh, uh, medially into the joint.

8:51

Okay. Questions or concerns on this? I'll pause for a moment.

8:56

Uh, Eddie. Yeah, uh, could you just, uh, uh,

9:00

talk me through the,

9:02

what they describe as the actuate segment of the longhead the

9:06

biceps, and where does the intraarticular segment end?

9:12

Uh, so, so you have to remember,

9:14

so the intraarticular segment is wh where arguably our arthroscopists can,

9:18

can still see the longhead, the biceps tendon. So I, uh,

9:22

the arcuate, uh, my understanding is where the, the pulley mechanism,

9:28

uh, is you typically right around here,

9:31

and it tethers or keeps that longhead biceps tendon in its appropriate position

9:35

as it dives down into the intertubular groove.

9:38

So my understanding is if, if it was the arcuate is somewhere, is around here,

9:43

where the pulley mechanism is, and then for me, uh,

9:46

what my orthopedist tells me is where the tubular

9:51

portion, uh, starts to occur.

9:54

That's what they deem to be extra-articular. But, uh,

9:57

whether that strict definition is correct, that I don't know. But mind you too,

10:02

um, you know, I tend to be more descriptive and I just, I just use,

10:07

um, I, I'll just use a ruler and, and provide measurements to my,

10:12

for my arthroscopist and, and, uh, shoulder, shoulder surgeon.

10:18

So here, for instance, if there's a,

10:20

let's say a longitudinal split tear of the long head of the bicep tendon,

10:23

I will give the degree, uh, of tendon, uh, involvement,

10:27

whether there's tendinosis and the tear, whether it's full or thickness,

10:31

or full or partial thickness. And then I'll, I'll,

10:34

I'll give a measurement of a la uh, uh, uh,

10:37

using a ruler with a, a from, from a landmark that, uh,

10:41

the surgeon can either palpate or see under fluoro or, you know,

10:47

you know, some sort of surface anatomy where that, that they can go off of.

10:50

So typically, if there's a tear of the extra articular portion,

10:54

or within that inter tubular groove,

10:56

you have to remember that the surgeon will sometimes also go in arthroscopically

11:00

and pull and tug back, pull the,

11:03

pull the biceps tendon in back into the joint so that they could work on it or

11:08

tag it or what have you, or even cut it, and then later, you know,

11:12

leave it as a tenotomy or a, or perform a tenodesis,

11:15

either doing a mini open or, uh, you know,

11:18

converting to an open after they've dealt with the, uh,

11:21

in intraarticular stuff in the cup tendons, uh, more proximally. I,

11:26

I hope that answers your question.

11:27

So you could say that the ate segment is the intraarticular portion

11:31

Of the Yeah, this intraarticular portion. So for me,

11:34

this intraarticular portion is from like biceps, labral anchors,

11:37

all the ways to like, where the pulley sort of, uh, you know,

11:41

encapsulates and ends, which obviously, you know, is consisting of the, uh,

11:46

superior glenohumeral ligament and the cortical humeral ligament,

11:49

forming that pulley mechanism, uh, keeping that bicep tendon where it should be,

11:53

as it makes this transition at that, you know,

11:56

and dives down into the, uh,

11:59

intra tuber groove and extending this to its, uh, uh,

12:03

radial tuberosity insertion. Yeah, thanks. No, of course.

12:08

Any other, uh, questions on case one? Alright,

12:12

There's mention of, uh, a dysmorphic cricoid. Uh,

12:15

so how do you actually decide,

12:19

Uh, for the coracoid? Uh, I don't, I, I,

12:23

I like a radiograph if possible. Uh, in honestly, and in in my eyes,

12:28

uh, it, this, this case, um,

12:32

is arguably dysmorphic, but I, I would have to look, look into that.

12:37

But, and then the other thing too, more importantly, if,

12:41

if there's subcoracoid impingement, but for that diagnosis, uh,

12:45

there are measurements, uh, depending on who you read, uh, what is it, like,

12:49

four or six millimeters or less. But the other thing to look for,

12:52

to help support that is obviously, um, uh, you know,

12:56

subscapularis tendon tearing, maybe a little bursitis too, but, but, uh,

13:01

I like to rely on, um, we, we use a little bit of, of ultrasound, uh,

13:06

uh, focused ultrasound or point, uh, point of care ultrasound pocus.

13:11

We basically just, I'll put the, I'll ask the patient directly, you know, to,

13:15

with one finger to point to where it's maximally tender,

13:18

and if they point to the anterior shoulder, then I'll,

13:21

then I'll check for subcoracoid impingement and things like that.

13:23

But basically what I'm looking for is bunching up the tendon and a and immediate

13:28

release, uh,

13:29

as the patient is internally and externally rotating their humeral head

13:32

underneath that, and looking for any catching of either the tendon and or bursa,

13:37

uh, bursal fluid in that region to,

13:39

to suggest the possibilities of corticoid impingement,

13:41

and then also try to give a, a, a, a measurement to.

13:45

So any other, uh, great questions on case one.

13:50

Yeah, so, so again, I don't, uh, so slap ones, fours,

13:55

nines all the ways through, I forget what we're at now, what number?

13:58

I think like 11 or 13, I forget. But again, sort of, uh,

14:03

along the lines of the salted Harris lesion that,

14:07

that we kind of went over, uh, one or two sessions ago.

14:12

I, I tend to just describe the labral tears

14:17

or the degrees of fractures and things like that. So here,

14:22

uh, on the labral tear, correct me me if I'm wrong,

14:26

there was also mention of, uh, like a slap nine, uh,

14:30

or 10 or something like that where you have near circumferential,

14:33

if not circumferential, labral tearing in this week's homework session.

14:37

But here, um, the, there is some debate, uh, here.

14:43

So here, posterior superior, there's already some labral tear here, but this,

14:48

this difficult to, to call, uh,

14:51

this labral tear in this case, and maybe this is portions of it here,

14:55

but what obscures really, uh, in my opinion, this, uh, labral tearing,

15:00

this abnormal labrum is that biceps labral anchor.

15:03

And you can see how robust, uh, this, uh,

15:07

biceps labral anchor is just torn and,

15:10

and sort of tendinopathic and degenerate, as you can see here. Um,

15:14

but that obviously cutting also into the common anchor of that biceps labral

15:19

anchor here and here, just another, uh, lance at it.

15:24

And you can see though, on this sagittal taking everything, this,

15:29

uh, biceps labral anchor from here to here in, in my opinion,

15:34

is all, uh, you know, abnormal. And that's why, uh, there was mention, you know,

15:38

of that sort of slap tear, and you can see how, how,

15:43

or I at least start, like to use not only, uh, you know,

15:47

the c coronals, but also rely on the axials and sagittals.

15:52

So here on the sagittals,

15:53

we can see that abnormal biceps tendon,

15:57

but also that anchor from here to here. But also,

16:01

as I mentioned earlier in the previous case, talking about labral tears.

16:06

We can see here, notice here that this biceps labral anchor is,

16:10

in my opinion,

16:11

from this measurement that I'm gonna provide from here to here.

16:16

But notice here how this posterior labrum just posterior to

16:21

that biceps, uh, the biceps anchor, this is also ab normal.

16:26

So we, we should be at least calling this degenerated at the least,

16:31

in my opinion, if not degenerated, sort of tear in this, uh, you know,

16:35

50 something year old patient.

16:37

So notice here how you have signal change posterior to that

16:41

biceps anchor. Um, that, so that's in, in my opinion,

16:45

this is gonna be all sort of posterior superior labral tissue that's sort of

16:49

abnormal here, and not then also cutting back posteriorly.

16:53

And then a couple clicks more inferiorly,

16:55

you have more normal dark T two hyperintense

17:00

triangular labral tissue. So let's go back up superiorly,

17:05

see here is starting to get gray. And here definitely, I think, you know,

17:09

we can confidently say that this is sort of abnormal, uh,

17:13

posterior superior labral tissue that's posterior to the

17:18

biceps labral anchor. You can see that right here. Okay, right there.

17:23

And then again, more la more normal labral tissue, both, uh,

17:27

anterior,

17:28

posteriorly and anteriorly as an internal reference on this axial weighted

17:33

sequence or this axial sequence.

17:37

So intuitively, you did think that the,

17:41

the sagittal sequence is the best way to look at slap tests.

17:44

I, I'll use a little bit of everything, because remember, for sagittal,

17:48

sometimes with your sagittals, what their, you know,

17:51

their three millimeter skip ones or something like that, depending on, you know,

17:55

if you, again, running isotropic or not, or you know,

17:58

how thin your slices are getting on,

18:00

especially on your three Ts or one point fives or whatever you're running,

18:03

sometimes just depending on, you know, the prescription of the plane,

18:08

you may just jump out of tears, right? Be it, you know, labral tears,

18:12

meniscal tears, and things like that. So I tend to use, I,

18:16

I tend to be a structural sort of person. I, I, I, I'll evaluate structures,

18:20

I'll try to evaluate structures in all three planes. So in this case,

18:24

I will, uh, if I was reading this case, uh, de novo,

18:30

um, I would keep, you know, I would reference, uh,

18:35

back and forth, you know, looking at, you know, this here

18:42

correlating with my sagittals here,

18:47

and then to my axials here. See,

18:52

so here I can tell that this labrum or this,

18:56

this sort of posterior superior labrum is sort of, you know, gray and,

19:01

and arguably, you know, fluid bright right here, right?

19:05

So correlating with that, the axials right here,

19:10

we can see again that this confirms, you know, that we are way,

19:14

we're way behind the, uh, biceps anchor, which ends right here, in my opinion.

19:19

So this, this abnormal signal is more posterior superior labrum,

19:23

if not posterior labrum here, see? And then here,

19:27

the posterior labrum is sort of gray. And then you can see with our,

19:32

you know, image localizing line,

19:34

we can see that this posterior we're sort of almost at what,

19:38

depending on how you label it,

19:39

this is like nine o'clock of the labrum or the glenoid right here.

19:43

This is posterior labrum, as you can see, right?

19:46

And then if you were asked this line,

19:49

this correlates more with anterior superior labrum in, in my opinion,

19:52

if assuming you can trust the, you know, your, your images and your,

19:57

your localizing, uh, lines, there's no misregistration on your,

20:02

on your magnet and your images there. But as you can see here,

20:05

this posterior labrum is already starting to look degenerated and sort of gray,

20:10

um, versus more inferiorly,

20:12

more normal looking triangular dark labrum here, and,

20:16

and cutting in more into the posterior inferior labrum. As we can see,

20:19

when we correlate with our, uh, from this line on our sagittals,

20:24

do that. So I,

20:26

I'll tend to use not just sagittals, you know,

20:30

and this is all tear and abnormal, but I'll use the other sequences to sort of,

20:35

uh, build my confidence and, and, you know, uh,

20:37

build my argument for calling tears. So labrum, labrum, again,

20:42

ASAM and glenoid can be very difficult. Um, you know, especially on a,

20:47

on a, you know, a study where you have a positive joint fluid and, and just,

20:52

and just to round that out, um, you know, um, you know, I,

20:56

I will say sometimes in, in these non-auto graphic studies, I'll say,

21:01

I'll say something to the extent that, you know, the,

21:03

the labrum is suboptimally valued owing to a paucity of native joint fluid,

21:09

you know, but there is, you know,

21:11

probable or likely tearing or degeneration of, of such and such, uh,

21:15

portion of the labrum.

21:17

And especially if it's a younger patient where they're contemplating, uh,

21:20

surgery, you know, debridement or repair, I, I'll, I,

21:24

I will suggest to my surgeon to, you know,

21:28

consider getting an orthographic study just to, you know,

21:31

just to put things to rest just to make sure. Otherwise, I, I,

21:34

I'd hate to send someone into surgery, and then it turns out, you know, uh, I'm,

21:39

there's a, you know, we're mistaken or, or, you know, uh,

21:43

were incorrect. But granted, sometimes the labrum does heal. So I've,

21:48

I have cases of those in my collection too, where, where the surgeon, you know,

21:52

doesn't operate for, you know,

21:54

a few months on at a time after the initial surgery or the initial, uh, mr.

21:59

And then they go in, they say, oh, it's, it, it wasn't there. Well,

22:02

then it could have been healed too, arguably, or, uh, you know,

22:05

we could have just missed it. So

22:11

I see that you've got a, um,

22:13

what would be a grad echo two mm slice sequence on the bottom right.

22:18

Uh, generally thinner slices are better to look at the label.

22:23

Uh, yeah, I mean, but, but I, I do, yeah, I, it just depends on the magnet.

22:28

And, and here at UCSD, we have a little bit of,

22:31

we do a little bit of teleradiology too.

22:33

So sometimes we don't have control on what sequences we do get, but at,

22:38

at our institution, what the, the,

22:40

the magnets that we do and the technicians that we do have control over, we,

22:45

our sequences are going to be a, a coronal and a sagittal T one,

22:50

um, a coronal, sagittal and axial, um, uh,

22:55

fluid sensitive, uh, fat suppressed.

22:58

And then another axial typically in either a, um, uh, uh, usually a PD,

23:03

non-fat set, something like that. Uh,

23:05

and then obviously if it's an Mr Arthogram, then, you know, we'll,

23:09

we'll get the T one flu, uh, fat suppressed, and then, uh,

23:13

AOR sequences as well. So that's, so usually our, our,

23:16

our dry or non-contrast shoulder MRIs are, are about six sequences,

23:21

but we're always dabbling with that. Uh, we, we, we deal with a lot of,

23:26

um, myositis in our, in our group and, and, uh,

23:30

tumors. Um, we, we have a huge cancer center, so that's why we, like,

23:35

we prefer to get T ones, uh, to better evaluate marrow and things like that.

23:40

Uh, there are some literature out there,

23:42

some authors believe you can heavily window a PD and still make it like a, uh,

23:47

a, a poor, a poor man's or poor persons or form through sort of T one.

23:53

But, uh, in our group, we, we tend to, we,

23:55

we really like a nice T one weighted sequence for anatomy,

23:59

especially that marrow. So, uh, we tend to do less gradients, um,

24:04

uh, for, we, we tend to do more fast spin, but our,

24:08

but our localizers tend to be gradients, obviously. So

24:12

Just one last anatomy question. Of course, of course. Um, it's just the, um,

24:17

you, you mentioned the intraarticular,

24:19

actual actuate part of the biceps tendent. Mm-Hmm. It's, it's a,

24:23

it's very busy area. So they, they use terms like, uh, the, uh,

24:29

biceps pulley, uh, complex actuate region, ov interval.

24:34

They all live in the same space. Yeah. And are those interchangeable terms?

24:39

Ah, the, the rotator, so the rotator interval, okay.

24:43

My understanding is, is just the space, okay.

24:47

Bounded by the anterior aspect of the supraspinatus, okay.

24:52

Here, right. So that's gonna be this area,

24:56

this sort of cone shape or triangular area that's, uh,

25:01

demarcated or bounded an, uh, bounded at its, uh, posterior aspect.

25:05

The rotator interval of that is the posterior border is gonna be the anterior

25:09

aspect of the supra, okay? Spinatus. And then the, uh, distal or,

25:14

or inferior or coddle aspect is gonna be the, uh,

25:19

superior portion of the subscapularis muscle and tendon. So this to me,

25:23

is all rotator interval. Okay?

25:26

And then the three important structures that run within this region are gonna be

25:31

the pulley mechanism,

25:32

which is comprised of the superior glen humeral ligament complex, okay?

25:37

And the cortical humeral ligament. Okay.

25:40

And through which then those things are gonna,

25:43

and then the third structure that runs through this region of the rotator

25:47

interval, which is surrounded by the pulley,

25:49

is gonna be that long head of biceps tendon.

25:52

So the way I think of it is the rotator interval, the pulley,

25:57

which is those two ligaments, and then through the pulley mechanism,

26:01

the long head of the biceps tendon runs and then dives down into that inter

26:06

groove as it courses, uh,

26:09

more distally to the biceps radial tuberosity at the elbow.

26:13

So synonymous, yeah, arguably, but, but sort of, uh,

26:18

you know, uh, in layers, if you will.