0:01

We have a 57 year old female with a

0:05

status post bike accident and pain and soreness, uh,

0:10

particularly when raising arm overhead, no prior surgeries,

0:14

so going with a similar setup. We have a couple more, uh,

0:17

additional sequences here, but sticking to sort of my format.

0:22

Um, so coronals on top, sagittal and axials on the bottom.

0:27

And what we see here, uh, as the positive aero sign shows that, uh,

0:32

you know, there's, uh, supraspinous and subscapular tendinosis,

0:36

and some of this tear, as we can see is fluid bright.

0:40

And we see, uh, uh, basically a tear of the, uh, supraspinatus tendon.

0:45

But the majority of this, and the crux of this, uh, um,

0:49

case is notice here that some of the tendon tear, uh, is arguably,

0:53

uh, intrasubstance. Okay. Some of you had marked on the,

0:59

your, uh, your homework assignments,

1:01

that there is some articular and intrasubstance tear. That's fine. I didn't, uh,

1:06

dinging you all for that. But the main point of this case was to, uh,

1:10

be able to call and mention that there's this sort of delaminating tear

1:15

of the, uh, involving the in infraspinatus tendon tracking medially, uh,

1:19

to form this intramuscular or so-called sentinel cyst, uh,

1:23

within the upper fibers of the in infraspinatus muscle. As we can see here,

1:27

this, uh, and I think it measured about a few millimeters,

1:30

but the important point of this case is to mention these intrasubstance

1:35

tears, uh, and describe them. And, and people will mention,

1:40

you know, um, other things like I, I, I saw, you know, paint, uh,

1:46

rim rent, pasta and things like that. Uh, I've gone, uh,

1:49

away from a lot of these, um, uh, acronyms of, of partial tears,

1:54

uh, and, and I've just become more descriptive over the years. What I find is,

1:59

um, some people, um, uh, and I think we, we have a case of pasta later,

2:05

which is partial articular cito, supraspinous tendon avulsion, uh,

2:08

which in my mind and some authors mind is synonymous with rim run,

2:13

ri rim run tears. And some people,

2:15

some of you'll call this a rim run tear the srap space, which is fine, but I,

2:20

I tend to describe more where I will say the length of the tear,

2:24

the dimensions in the medial lateral dimensions.

2:27

So not only in this dimension, but also in the AP dimension.

2:32

And what I also give is a thickness. So I, I'll mention what,

2:35

what I think is the prop, uh, appropriate or the approximate thickness, uh, uh,

2:40

of involvement.

2:40

And I'll leave it up to the surgeon to negotiate with the patient what,

2:45

what the, uh, surgical or physical therapy management is going to be.

2:49

But typically, our surgeons, uh, 50% or more, they're,

2:52

they're gonna want to go in and, and debride and, and, and fix, uh, these, uh,

2:57

cup tears. But the important thing is to, to note, and,

3:00

and sometimes I'll mention these in my reports,

3:03

these intrasubstance tear can be concealed, uh,

3:07

interstitial or inter, whichever term you decide to use,

3:11

they can be concealed at the time of a arthroscopy. And that's my macro,

3:14

that's my saying for, for, for that. So I will, you know, I I I,

3:19

I would read this if pressed, you know,

3:21

supraspinatus and infraspinatus tendon tear with, um,

3:26

articular and intrasubstance tear,

3:29

particularly of the infraspinatus tendon where there is a delaminating component

3:34

measuring X by X millimeters and creating a so-called,

3:39

uh, you know,

3:40

a few millimeter sentinel cyst or intramuscular cyst at the mild tendinous

3:44

junction. And, and this portions of this intrasubstance care may,

3:50

may be concealed at the time of arthroscopy. And that's how,

3:54

that's how I will word it in my findings and also bring it down into my

3:59

impression. And also here, uh,

4:01

some of you had called some subscapular tendinosis and tear, and that's,

4:06

that's totally fine too. There is some, arguably some, maybe some, you know,

4:10

maybe some fluid bright, uh, signal right here or near fluid bright, which may,

4:15

uh, push some of you to call a tear or,

4:17

or raise the possibility of possible or probable tear in this, uh, 57 year old.

4:23

Other findings too, that I want to just point out, okay, typically,

4:27

usually anyone above, unfortunately, as we all get older, uh,

4:31

we're gonna get degeneration and, and, and, uh, collect things as we age.

4:36

And here, as you can see, most people in, in my opinion,

4:40

45 to 50 years old, including myself,

4:42

we're gonna have degeneration the superior labrum. That's where it happens.

4:46

And this is what it looks like for those that are not as comfortable calling,

4:50

uh, labral tears. What I like to see, okay, is, uh,

4:54

fluid bright or near fluid, bright signal,

4:57

at least extending into the labral substance and cutting away from the

5:01

patient's head. As in this case here,

5:03

we can see that it's directed into the labral substance and going away

5:08

from the patient's head,

5:10

if this fluid signal was conforming to the glenoid, uh,

5:14

surface and running towards the patient's head,

5:17

and typically at that one to three o'clock position,

5:20

then I'll start using the terms labral, you know, recess, s foramen hole,

5:24

whatever, normal variance at that one to three o'clock position in the, uh,

5:28

glenohumeral joint over shoulder MRIs that you read. Okay?

5:32

So this just a nice case of a concealed intrasubstance or interstitial tail

5:37

that may be hidden at the time, arthroscopy with, uh, some delamination,

5:41

particularly the in infraspinatus tendon. So for that, I'll,

5:44

I'll pause for a moment and, and, uh, we can discuss this, uh,

5:49

CID or, or interstitial delaminating sort of, uh,

5:52

and potentially concealed type tear.

5:57

Um, there's a mention that, uh, PD fat set, uh,

6:00

will pick up all these degenerative changes of the labrum,

6:03

but is it useful to have AT two sequence to distinguish it from a actual tear?

6:09

Uh, yeah, some people will rely more on T twos and,

6:13

and get non-fat suppressed too. Um, and again, it's just, uh, it's,

6:18

it's knowing your magnet. Every magnet I is a little bit different,

6:22

and it's just getting accustomed to the images that your magnets, uh, uh,

6:27

come across or, or, or, or put out. Um, some people, uh,

6:31

prefer PDs. Some people prefer T twos with fat, fat.

6:35

Some people will prefer just, uh, just a, uh, they'll get a,

6:38

a fluid sensitive fat suppress as well as AT two non-fat sat to, uh, help,

6:43

uh, you know, build that sort of confidence as well. So, yeah.

6:48

Is there a time penalty for first pit echo T two to be placed in?

6:52

'cause I know my institution doesn't,

6:55

Uh, yeah. I mean, there's always gonna be, you know, it's all,

6:58

there's always gonna be trade off if you want, you know, an, uh,

7:00

a couple extra sequences and things like that, you know, with, with a,

7:04

with AT two, uh, like a non-fat set, like here, uh,

7:09

this looks to me like AAAT one and, and a, you know,

7:13

AT two, I guess, uh, PD or a PD fat sat.

7:16

But if some people throw on that T two non-fat sat, you know,

7:20

then that's another penalty of, you know, whatever, five,

7:22

10 minutes or something like that, whatever it is, uh, on your magnet. But yeah.

7:27

Um, but in, in all, honestly, for me, at least, I, I'll probably use these,

7:32

these four sequences when, when I'm, um, reading most studies.

7:36

And obviously it would be different for an Mr. Arthogram.