0:00

So this is a 50 something year old with

0:05

pain for six years, crescendoing since December, 2012.

0:09

No known injury di difficulty moving the arm.

0:13

So here we have a localizer sequence.

0:15

So I combed through that as my initial checklist,

0:19

and then throwing up my usual coronals on top,

0:23

and then a SALs and axials on bottom.

0:29

Okay. And going right to the, uh, the money on this case.

0:33

And what we see here is some,

0:38

let me window this better for everyone. Here we go.

0:43

Just to bring out the, the finding.

0:45

We see here that we have some TT one and T two, uh, uh,

0:50

dark, uh, hyperintense structure,

0:53

sort of gular and appearance involving, uh, mainly the, uh,

0:58

junctional fibers of the supraspinatus end infraspinatus tendons looks at,

1:01

looks to be at least a few sub centimeter deposits.

1:05

And these are consistent with calcium hydroxy appetite in the, uh,

1:09

supraspinatus and infraspinatus tendons at the near their footprints.

1:13

Some of you use the term foot plates, that's fine, whatever, uh, terms you use,

1:18

just, uh, but our surgeons like to use footprint,

1:20

so that's what we use at our institution.

1:23

But we can see here that some of those, uh,

1:25

deposits are also extending into the, uh, uh,

1:29

subacromial subdeltoid bursa. And arguably also, uh, maybe, uh,

1:33

some early extension into the, uh, the greater tuberosity. And that can lead to,

1:38

um, uh, uh, a sort of, uh, uh, uh,

1:43

robust marrow edema that can often be confused for tumor infection and

1:48

trauma. Okay, so, so ha had, uh, in the,

1:53

it can be divided for calcium hydrox heide, which I'll call had for short, uh,

1:57

just for brevity. Um, you know, had, uh,

2:01

typically loves the most common location in the body is gonna be the

2:05

supraspinatus tendon of the shoulder.

2:07

Other locations that it loves to involve is the greater t trochanters about the

2:11

hips and also the hamstring origins. But if you're thinking this diagnosis, the,

2:15

the, the easiest way to, to cinch this diagnosis is,

2:19

is just to correlate with radiographs and just to see that, uh,

2:22

calcium hydroxide deposition,

2:24

which is gonna be obviously hyperdense on your X-rays or cts if you

2:29

don't have it, or in the op chance that your,

2:32

your had is undergoing the resorptive phase. Um, it can,

2:37

in that phase, it can be painful and you won't see the head as it gets resorbed,

2:42

okay?

2:42

Or gets dispersed or runs into the intramedullary cavity or the bone nearby bone

2:47

or into the muscles. As arguably this case, the head, uh,

2:52

could have been tracking into the, um, the, uh,

2:55

supraspinous muscle barrel belly here, sort of posteriorly.

2:58

And that can lead to a misdiagnosis of myositis, okay?

3:03

When it runs into the, uh, the muscles here. All right? So,

3:08

um, and that also easy diagnosis under CT or x-ray if you have it.

3:13

But if not, uh, something to think about, especially, you know,

3:17

you don't want to be confusing this with, uh, you know,

3:20

neoplastic disorder of the muscle or bone if it's running into either of those

3:24

structures. And you could imagine, uh, uh, quite often, uh,

3:28

at least once or twice a year, we get a referral for hat at our institution.

3:32

For some reason, it's very common here in San Diego. Uh, maybe it's the water,

3:36

maybe it's the, uh, active lifestyle or, or just sun. So people are always, uh,

3:41

out and about, uh,

3:42

maybe forming this head with muscle or muscle and tendon injury. Um,

3:47

so they'll present with, uh, extreme excruciating pain. And,

3:51

and we can offer at sometimes, uh, ultrasound guided baritage,

3:55

particularly for lesions that are one centimeter or less,

3:58

and look sort of cloud-like, or on their way to that resorptive phase.

4:03

If it's early on in that more formative phase, it can lead to, uh, impingement,

4:08

uh, uh, of the tendon as the patient is, uh,

4:12

abducting the shoulder in this case. So something to look about.

4:16

The other differential diagnosis for had is going to be just a torn

4:21

tendon that's sort of retracted in globular, but in those sorts of cases,

4:25

you can look for a fluid, bright signal and, and tendon gap. So, but here,

4:30

as, as we can see here,

4:31

the tendon is dark along with the calcium hydrox peptide deposition, and,

4:36

uh, you know, just ask for a radiograph or prior radiographs. Uh,

4:40

but if you don't have the radiograph, the other thing that I, uh,

4:43

that I do do sometimes, and I have a special interest in, had we published it,

4:48

published on this, uh, once or twice, um, I, I will ask for,

4:53

um, uh, radiographs of other joints like the, um,

4:58

the, uh, hip, you know, or ask for a ct,

5:01

a abdom and pelvis to see if there's other deposits I've had at other locations

5:05

to support this, uh, potential diagnosis if I don't have a shoulder radiograph.

5:10

So this just a nice case of calcium, my appetite of the, uh, junctional,

5:14

fibro supraspinatus, andin tendons and, uh,

5:17

starting to migrate or maybe involve a little bit of the subacromial hyphen

5:21

subdeltoid versa with a little bit of bursitis. So that's, uh, uh,

5:25

a nice discussion of that case. Any questions on had of the shoulder?

5:30

Great questions,

5:32

Eddie. One last question. Hopefully a quick one. Yeah, just looking on the, um,

5:37

sagittal images there at the superior fibers of the subscapularis.

5:43

I find when I'm reading shoulder Mr.

5:45

That I often have some high signal that, uh,

5:49

extends from above and possibly into those superior fibers,

5:52

and I don't know when to, uh,

5:53

interpret a tear or is it just a bit of fluid in the subc cricoid bursa?

5:59

Um, so yeah,

6:01

Yeah, great question.

6:02

So where, where are your landmarks?

6:04

So, so, so remember, so this, so, okay, so, so the subscap,

6:08

so let's take it. So subscapular recess, as we know,

6:12

communicates with the joint. And then to me,

6:15

this is all subscapular recess.

6:17

Some of you and some of my trainees call this the subscapular recess,

6:21

but that's this right here,

6:24

and that's underneath the undersurface of the corco process or that crow's

6:29

beak. And this communicates with the joint, okay?

6:32

Typically through a little fenestration or something like that.

6:36

So it's all this stuff right here. Okay? So this to me is all that, right?

6:40

So now there's, and if you read Lenny Steinbach, okay, Dr. Steinbach out of,

6:45

uh, UCSF, San Francisco, she's one of the originals that put out the,

6:50

the initial radio radiologic anatomy on MRI in the journal radiology.

6:56

And according to her and her, uh, drawings, there's a,

7:01

um, a, a joint capsule or a synovium or,

7:05

or a lining if you were a border right around here, okay?

7:09

And anything below this, typically, like at about the,

7:12

the tip of the cricoid process, if you see fluid down here,

7:16

that's the subcoracoid bursa, okay?

7:20

That bursa communicates normally with the subacromial

7:25

hyphen subdeltoid bursa. Okay?

7:27

So if you have fluid out here, as in this case in theory,

7:32

this subdeltoid bursal fluid could also communicate

7:37

with the subcoracoid bursa. Okay?

7:40

So typically I'd like to see it, maybe this is some of it right here,

7:44

but the differential for this is gonna be if you're too far, uh,

7:49

lateral, then that can also be teno synovial fluid, okay?

7:53

Of the biceps tendon that's fooling you. But in my mind, this, arguably,

7:57

this subdeltoid fluid is communicating with the sub choroid bursa,

8:02

which is this fluid right here, okay?

8:05

Not to be confused with this little bit of teno synovial fluid within the bicep

8:09

tendencies. So to me,

8:11

this is all subdeltoid communicating with subcoracoid.

8:16

And we can see here going back and forth,

8:18

we are way inferior to the coracoid base and, and process.

8:23

And we can even see that, uh,

8:25

portions of that subscapular recess or that subscapularis recess.

8:28

Some of you call, and then that's this right here.

8:31

So anything sort of inferior to this region right here,

8:34

we're where we're starting to see a lot of that lesser tuberosity and

8:37

subscapularis tendon footprint. To me, that's subor bursa,

8:41

which is right around here. Okay? The other thing to answer your question,

8:46

okay, most times the subscapular tendon, in, in, in anecdotally,

8:51

in my opinion, it's gonna tear at these upper fibers, okay? And,

8:56

and, and it hasn't been, or it's people are starting to,

9:01

to, uh, you know, talk about it now and,

9:04

and in the literature as of late in a few years back. But there's a common, I,

9:09

I'm starting to think more and more that we're just a com we're,

9:11

there's just common aosis and sleeves that are shared between all the

9:16

fascia, the, the ligaments and, and tendons throughout the body, okay?

9:21

And here, in this case, in this region,

9:24

the transverse ligament that covers the, uh, and keeps the,

9:29

uh,

9:29

long head of the biceps tendons situated within the intra tuber groove between

9:34

the greater and lesser tuberosities,

9:36

it's been shown histologically that that shares a,

9:40

some common histo histology and fibers with the subscapular

9:45

tendon footprint. Okay? And some of you that are studying the literature,

9:50

um, there, there is what's called a, um,

9:55

a slap tear. And I forget the, the acronym or the, what it stands for,

9:59

but it's basically you can get anterior fibers of the

10:03

supraspinatus tendon,

10:05

which also bleed into tendonous fiber,

10:09

tears of the upper fibers of the, uh,

10:14

subscap. And they also, some authors call that a slap, okay?

10:19

A slap tear, but not to be confused with the labral tear. Okay?

10:23

This is a superior, I forget, it's,

10:26

it's called like a anter superior rotator cuff tear,

10:30

which involves the, uh,

10:32

anterior fibers of the supra and superior fibers of the subscap.

10:37

So that's another reason why I don't use slap tear,

10:40

because some people confuse that with, uh, the actual labral tear,

10:45

the original slap, okay? That was, uh, described, you know,

10:49

one through three and, and four initially on and later expanded to,

10:53

I forget now, types 11 through 13. Um, um, but,

10:58

but also with, um,

11:00

the cuff tears that happened anterior superiorly that involved the

11:05

supra and subscapularis. But typically, to answer your question,

11:08

the subscap tears lo love to involve this, uh,

11:12

upper fibers of the subscap.

11:14

And what I'm looking for is morphology and signal thickening,

11:18

irregular morphology and fluid bright. And, and that's my other, I've,

11:23

I've added that as another checklist. Now when I have these,

11:26

an far anterior fibers of the, uh, supraspinatus also, uh, tendon torn,

11:31

I'll look at the upper fibers of the subscap,

11:33

and you'll see it more times than not with sometimes a little bit of the

11:37

lamination as well. So, great questions.

11:40

That's excellent. Thank you. I, so can we just scroll a little more medially on,

11:44

on the sagittal and go back to the cricoid process. And, uh,

11:48

basically what we're seeing here is just some edema of that subscapularis

11:53

recess.

11:54

Yeah. So some fluid within that subscapular recess, in my opinion, right here.

11:58

Yeah, yeah, yeah. That, that normally communicates with the joint, right? Yeah.

12:02

And then if you're reading osteoporosis, you'll oftentimes see synovitis,

12:06

right? Little bodies,

12:08

little little glenohumeral joint bodies that go into this.

12:12

And then oftentimes what I'll see in,

12:14

in our orthopedic oncology rounds is someone will call

12:19

a sclerotic lesion projecting over these, uh,

12:22

superior glenoid or the scapular neck. And what it happens turns out to be,

12:26

is just a body, uh, related to severe glenohumeral joint that's just,

12:31

uh, found itself into the, uh, subscapular recess,

12:36

analogous to like a body within the popal, uh, popal recess of the knee,

12:41

if you want to think of it that way.

12:42

It's just like another pop-off valve for this joint, in this case,

12:46

the glenohumeral joint.

12:49

That's great. Thank you so much.

12:50

Of course.

12:53

Um, Eddie, the capsule of the shoulder joint, um,

12:56

generally knowing that there's a rent or tear of the capsule,

12:59

it's only best defined when there's a lot of joint fluid,

13:03

or can you actually see it any other way?

13:05

Uh, yeah, joint fluid. Joint fluid, yeah. And then, then,

13:09

then we started to get into the bait too, you know,

13:11

whether you add all these ligamentous structures as part of the capsule, right?

13:15

Some people think that the ligaments are just thickening of the capsule,

13:18

and then we can, we can have a, a whole debate about that. So, you know,

13:22

the superior glen, the superior middle and anterior band and stuff like that,

13:25

some people call that capsule too, but they just call it capsule la uh,

13:30

capsule ligamentous complex, just, just for those that are studying, um,

13:34

you know, just something to be aware of. So you may call that capsule as well.

13:38

And then also we, we put that in our literature. Be careful, you know,

13:42

especially when you're doing your MR arthrograms,

13:44

if you pump more than 12 ccs total right? Uh, into your shoulders,

13:49

you can burst the capsule so that that can make reading, you know,

13:52

capsular and ligamentous and rotator cuff tendon tears, very difficult, right?

13:57

Especially if, you know, so be, be mindful of how much, uh,

14:01

contrast you're pumping into your shoulders, right? So you could, you can, uh,

14:06

you know, be masking, uh, making, making things more difficult for you to read,

14:11

especially if you are, you're putting in more than 12 ccs of, uh,

14:14

total contrast, the lidocaine your saline, and your, uh,

14:18

omni and sometimes people do steroids at the same time. So keep a,

14:22

a mental track of how much contrast you're putting into your joints.

14:25

So I've run into that sometimes too.

14:28

And the weakest point would be in the axillary pouch where,

14:32

where it tends toter easily or it's more

14:34

Positive. Yeah. That, that, that I don't know. But, but if you google, um,

14:38

some of my colleagues Wilbur Wong, okay? Uh, we have put out an article,

14:42

ar article in AJR actually that, uh,

14:46

says that if you have a posterior band tear, okay,

14:50

without anything else, that's usually going to typically be iatrogenic, right?

14:55

But also remind you too, if,

14:57

if you are the one that's doing the arthogram art fluoroscopic arthrogram or

15:01

ultrasound arthrogram, if you are feeling resistance early on, okay,

15:06

and you get a good history that this patient could have had, um,

15:09

adhesive capsulitis, that's another reason why you may burst the capsule. And,

15:14

but sometimes with those patients, you,

15:15

what you'll see is contrast tracking underneath the subscapularis muscle belly

15:20

along the subscapularis fossa. And that's,

15:22

that's a diagnosis to keep in mind too. So sometimes when I see that,

15:26

and if I did the contrast study and I,

15:28

I don't see contrast going anywhere else beneath, uh,

15:32

at the axillary pouch that is, and it's cutting through the sub subscapularis,

15:36

uh, fossa here underneath, uh, interpose between the sub,

15:40

the scapula and the subscapularis muscle, I will raise the possibility, Hey,

15:44

were we thinking about potential adhesive capsulitis originally,

15:47

which is usually a clinical diagnosis, but these days we,

15:51

we do see it quite often on our Mr non-contrast studies. Yeah.

15:56

But the proven weakest point that, that, I don't know,

16:01

I, I'm sure if you pump, if you distended enough joints, you know,

16:05

most joints are gonna fail at some point. But, but what that is, what,

16:08

what order that is. I don't,

16:10

I don't know of a good article that that's shown that, but great question.

16:15

Uh, is it a common practice in the us Do you do hydrodilatation for adhesive

16:19

capsulitis?

16:20

Yeah. Yeah. Uh, and we do it, we do it, uh,

16:24

on the same day or the day before, physical therapy. Um, but, uh,

16:29

you know, and, and we'll, we'll try to do, uh, little bit of steroids and then,

16:34

and then we'll send them off to physical therapy, um, you know, and,

16:37

and sometimes we burst the capsule and then they'll feel immediate relief,

16:41

which is, which is great. Sometimes we don't. And, uh, uh, personally,

16:46

uh, the record for us before a capsule would burst was in like,

16:51

I think it was like some, some remarkable number,

16:53

like close to a hundred ccs mm-Hmm. So it, it does happen rarely.