0:00

History we are given is a 65 year old female with pain,

0:03

with overhead movement and weakness of the rotator cuff. Again,

0:08

coronals on top, sagittal and an axial and bottom.

0:13

Okay. And, uh,

0:15

what we have here is obviously some supraspinatus and in

0:19

infraspinatus tendinosis, but, uh,

0:22

this tear mainly articular sided,

0:25

probably involving about 50% or more of the tendon thickness.

0:30

And again, I would give, uh, measurements in the AP plane and the,

0:35

uh, medial to lateral plane.

0:37

But some of you had used the term pasta. Okay. Uh, and,

0:41

uh, uh, again, uh, for those that came joined a little bit late,

0:46

um, I have, I used to memorize in my mind what all these,

0:51

um, uh, acronyms or these, uh, uh, partial tears are.

0:56

And again, you can divide rotator cuff tendon tears into, excuse me,

1:01

full thickness, which is o uh, obviously easier to call.

1:05

But when we start calling these partial tears,

1:07

and then that starts to bring in the alphabet soup of all these acronyms to

1:12

remember whether, you know, if your surgeons use them, please by feel, uh,

1:17

by all means, I, I will read to the surgeon, but again,

1:21

if the surgeon doesn't mind me not, uh, providing some of these, uh,

1:25

partial tear acronyms that is, uh, pasta rim, rent,

1:30

paint, um, what have you, I will just, uh,

1:34

give the exact, try to give exact measurements and be more descriptive.

1:38

So in this case, I'll give the measurements.

1:40

In millimeters mentioned that it's about 50% thickness, uh,

1:45

articular sided and which tendon is involved.

1:47

But some of you had used the pasta, or, and some of you,

1:51

I even saw used the term, uh, like an exaggerated rim rent tear.

1:56

That's fine too. But, uh, um,

1:59

this probably fall closer into the pasta realm. That is the partial,

2:04

uh, thickness articular cited supraspinatus tendon avulsion.

2:09

And the reason why I've used, I,

2:11

I've stopped using the acronym pasta is because I don't always get the,

2:16

the, um, the history of an acute, uh,

2:19

event to call an avulsion. So it's sort of semantics and getting academic.

2:24

And then also with the po, the past lesions, depending on who you read,

2:28

these pasta lesions can also happen from degeneration. So, uh,

2:33

you know, some authors will go back and forth, you know, to call an evulsion.

2:36

They like to hear an acute event. So rather than, um,

2:41

uh, dealing with that conflict, uh, I,

2:44

I tend to just become more descriptive.

2:47

And then also I find too that, uh, some of the, um,

2:51

support staff for the orthopedist may not be familiar with all the acronyms.

2:56

And that's why I also find that it's, it's more, um, for,

2:59

for in my practice at least,

3:00

to be more descriptive and just call and describe the tear. But, uh, and,

3:05

and then I will put, um,

3:07

pasta or partial articular sided super spinous tendon,

3:11

ul or rim rent in parentheses for those, um, surgeons that like to, um,

3:16

still deal with those, uh, sort of, uh, memory tools and, and those sort of, um,

3:21

uh, those, those descriptors and that terminology. So I'll,

3:25

I'll tend to read for my clinician, certainly. So this just a nice case of, uh,

3:30

supined tendon tear at the footprint of footprint or so-called al lesion,

3:35

uh, with some, uh, um, um,

3:39

e extension to involve the, uh, near the, uh, um,

3:43

the more articular sided fibers near the footprint,

3:46

and maybe even towards the cable here, uh, right here.

3:50

So that's, uh, that case here.

3:55

Could you take us through the labrum on this one?

3:57

I sure was under the impression that it was torn,

4:00

but I can see that it's read out as not.

4:04

Yeah. So, so some of, some of us, uh, uh, are, uh, argue that this,

4:09

this labrum was at least degenerated. Um, and especially superiorly,

4:14

especially in a 60 or 70, some someone year old, you're gonna have that,

4:19

um, this, I'll try to window it. Um, this was,

4:23

I believe, if I remember correctly, not an obvious tear,

4:26

but some of you had Reddit as potentially a tear or

4:31

degeneration. That's fine. And, and that's, that's to be expected,

4:36

uh, in, in this, in this patient, especially someone that's 60 something,

4:41

60 something years old. But also what I want to point out, uh, you know,

4:45

there's arguably some, uh, glenohumeral cartilage loss, and I, I,

4:50

I tend to put more stock, uh, in the gla in the cartilage, uh,

4:55

rather than labrum. Because for me, the labrum, although a,

5:00

a stabilizer, the whole point of the game is to preserve cartilage.

5:04

And some of you have even pointed out that there's some, arguably, maybe some,

5:08

uh, osteoarthritic bone marrow edema at the posterior glenoid,

5:12

perhaps indicating some overlying, at least high grade, uh,

5:15

chondral phishing there. And if I graded your case in that case, I, I,

5:19

I wouldn't have have dinged you. But, um, if, if push comes to shove,

5:25

you know, yeah. You know, if,

5:26

if the surgeons really wanting to know if there's a labral tear, then, you know,

5:31

you could in theory do an arthrogram in a 67 year old. But typically,

5:36

um, for my patients, uh, especially if they're on the more elderly side,

5:41

I'll just call labeled degeneration, non degenerative type tearing, uh,

5:46

particularly superiorly here as we can see. So, um, it,

5:49

this one arguably sort of, you know, back and forth, uh, between all,

5:54

all of the homework cases that I, that I graded. But, um, the, the master sheet,

5:59

I believe did say no tear. But, you know, I tried not to come down too hard,

6:04

um, and dinging everyone if you, if you said, uh, you know, labral tear.

6:08

But if I did, I apologize.

6:11

No, thank you. That's helpful. Of course. On, on on the axial images,

6:14

can you just take us through the structures we see the anterior labrum and,

6:17

and where is the middle humal ligament coming through?

6:21

So, so the way I look at the labrum, um, you know, e especially, uh,

6:25

you know, an m arthrogram or, or someone that's younger,

6:28

where we're gonna worry more about labrum, uh, you know,

6:32

especially someone's dislocated.

6:34

What I tell my trainees and what I've learned over the years is I actually start

6:39

with the posterior labrum, okay? And the reason being is, uh,

6:43

so I'll walk down the posterior labrum,

6:45

but I'll look at the superior labrum first. You know, if there's a, a sort of,

6:49

uh, you know, AAV shape of contrast,

6:52

a little bit of convexity towards the humeral head, and if that, uh,

6:57

fluid signal also runs posterior to the biceps labral anchor,

7:01

which is probably right here. So if I see some contrast, uh,

7:05

if it's an M arthrogram or a fluid signal bright,

7:07

then that's an easy labral tear call for me. Then I'll scroll down posteriorly.

7:12

And the reason why I walk posteriorly is because the inferior, the,

7:16

the anterior band of the inferior gland humeral ligament complex,

7:19

as some of you may have no may know, has a high attachment.

7:23

So I try to pick up the anterior band,

7:25

which I think arguably is this structure right here of the inferior gland

7:30

humeral ligament complex. And then I'll, I'll scroll up in a, uh,

7:35

coddle to cranial fashion, or inferior to superior,

7:39

looking to see where that, uh, uh, that band,

7:42

that anterior band has attached upon the, the capsule ligamentous complex.

7:47

So here, I argue it's probably attached here, uh, sort of,

7:52

uh, if we could pull up the sagittal at the same time,

7:57

it's attaching it sort of inferiorly,

7:59

sometimes this anterior band will attach high superiorly,

8:04

and then it can, it can mimic, um, a labral tear.

8:08

So that's why I like to scroll, scroll down posteriorly,

8:12

and then walk back up the anterior labrum from, from an inferior to post,

8:17

uh, superior direction. So here, to me, that's all anterior band.

8:20

So anything here, I'm gonna shy away from calling the labral tear. But here,

8:25

going a couple more clicks, superiorly, we see relatively more normal labrum.

8:30

And then here, this anterior superior labrum is looking a little bit ratty.

8:34

And I would raise the possibility,

8:36

or I'd be concerned that there is maybe at least some degeneration or

8:39

degenerative tearing here. Some of you may have not have called it, that's fine.

8:43

But to my eye, this is a little bit irregular. So I'd raise the possibility,

8:47

especially if it's someone younger and if they're complaining of micro

8:51

instability when, when they're insulin rotated and the pa uh,

8:54

and the surgeon sort of pulls down on their shoulder,

8:57

that can be a sign of that micro instability with that anterior or anterior

9:01

superior labral tear in these younger patients. So, but if worst case scenario,

9:05

especially if it's, uh,

9:06

if it's a non-contrast or non Mr non orthographic study,

9:11

then I will recommend, uh, getting an arthrogram, uh,

9:15

study to, especially if they're contemplating, um, uh, shoulder surgery.

9:20

'cause I, I, you know, just to be sure, you know, that there is, uh,

9:24

a sort of labral tear in there. And that also, you know, along those lines, uh,

9:28

the other reasons why I like to scroll from inferior to superior on the anterior

9:32

labrum is, you know, you can get, uh, you know,

9:36

a Buford complex that could confound things where you have, you know,

9:40

no anterior superior labrum, and then just that thickened,

9:43

middle glenohumeral ligament. Or sometimes too, you can get like a,

9:46

a detached and floating sort of labrum, what's been called a, um,

9:51

what is it called? A glenoid, labral ovoid mass or glom,

9:55

GLOM for short. Other things that you can happen as AG glad lesion,

9:59

Glen glenoid, labral articular defect. And sometimes that,

10:03

that little flap of cartilage can flip sort of anteriorly or even

10:08

inferiorly into the, uh, um, axillary pouch and mimic, uh, uh,

10:13

some lab torn labral tissue. So those are some reasons why I, I tend to use,

10:18

uh, the axials, coronals and Sagittals, um,

10:22

to really try to evaluate the labrum.

10:24

And I tend to evaluate the labrum sort of last, 'cause I,

10:27

even though I've been doing this now for, uh, I don't know, about a decade, uh,

10:32

just as an attending, I find the labrum of the,

10:36

of the glenoid and the acetate very hard to, to call sometimes,

10:40

especially when there's a paucity of, uh,

10:44

glenohumeral joint fluid helping, uh, to, uh, better evaluate the labrum. So,

10:49

and I will give some of those, uh, caveats and hedges, um,

10:53

if it's a non orthographic, uh, study, and very little, um, uh,

10:57

joint fluid to help evaluate the, the labrum adequately.