0:00

History of dull right shoulder pain after surgery,

0:05

reattachment three months ago, difficulty with all movements and weakness.

0:11

So just setting up, uh, as usual coronals for me on top,

0:15

sagittal and the axials on the bottom. Um, obviously, uh,

0:19

assuming we've already looked at the localizers, uh,

0:22

at the larger field of view. So the key to this case is the, uh, the,

0:27

so-called, uh, paint lesion. Okay. Um, but I'd like to highlight and,

0:32

and that acronym stands for, I always have to look it up. I applied, uh,

0:35

partial articular intrasubstance, uh, um,

0:40

tear of the, uh, supraspinatus tendon. But the key to this, uh,

0:44

case is, uh, what we're trying to show is this, uh, delamination.

0:49

And so-called, some people term it as differential retraction of the,

0:54

these torn tendon, uh, articular sided fibers.

0:59

So the way I have, or, or the way I would read this case is, uh, basically,

1:04

um, a moderate grade articular sided tear of,

1:09

uh, measuring, uh, x, uh, or y uh, thickness in, uh,

1:14

cranial coddle dimension.

1:16

And there's a small delaminating component where, uh,

1:20

causing differential with, with differential retraction of the torn, uh,

1:25

articular sided fibers, uh, here by approximately,

1:31

uh, 12 millimeters. And

1:36

there is additionally

1:44

about four millimeters of,

1:47

of a fluid cleft interposed between the torn bursal, or, sorry,

1:52

the intact, more intact bursal sided fibers and the torn and retracted, um,

1:57

Articular sided fibers compatible with, uh, a,

2:01

a minimal or a touch of, uh, delamination.

2:04

Um, and, and the

2:06

Key. But the key to this, uh,

2:08

case is just to mention any sort of intrasubstance or delaminating

2:13

tear. Now, there's, uh, many, uh,

2:18

definitions, uh, over the years, depending on who you read, what, uh,

2:22

constitutes, uh, delamination.

2:24

Some people give it like a measurement of like one centimeter.

2:27

Some people define it as a cleft of,

2:31

of fluid in between the tendon substance, uh, tendon substances.

2:36

Um,

2:37

But

2:37

I just basically look for, and, and I'm just more,

2:40

I've just become more descriptive over the years, and I don't use acronyms, um,

2:45

you know, paint, rim rinse, pasta lesions, what have you. Um,

2:50

I have, um, over the years, unfortunately,

2:54

With

2:54

Age, those, those terms have been expunged for, from my, uh, my memory.

3:00

Uh, but more so because, uh,

3:02

when working with my orthopedists and my sports medicine docs,

3:06

they prefer me to just describe and try to give measurements to the best of my

3:11

ability. And if you read JBJS articles and,

3:14

and at the anatomic literature, um, some cool things that I,

3:19

I wanna try to share with y'all, if I may. Uh,

3:25

the, some interesting anatomic literature has shown that,

3:30

uh, the cuff, uh, particularly the sup and infra,

3:33

it consists of about five layers and working from, uh,

3:38

superficial to a deep layer. There's, uh, the first layer, um,

3:44

is, and I, I'm happy to share this article with you, with you all,

3:47

but the first layer is, uh, consists of the, um,

3:52

contributions from the corco humeral ligament, then the deeper layer, uh,

3:57

there's tensile fibers that are basically run parallel or longitudinally

4:02

along the, uh, fibers of the tendons, the rotator cuff tendon.

4:06

And that allows for tensile strength.

4:09

The third middle layer is a thicker layer. And, and mind you,

4:13

all these layers about are about, uh,

4:16

one to two or even up to three millimeters thick. Okay?

4:20

The third layer is a layer that, uh,

4:22

where the fibers run at a cross hash or at about 45 degrees to each other,

4:28

okay? And then there's a fourth layer where there's just, uh,

4:33

sort of fibro lar sort of connective tissue. A and then,

4:38

uh, the last layer is the joint capsule.

4:42

And the joint capsule also has a perforating portion at the far

4:47

anterior aspect of the supraspinatus, if I'm remember correctly.

4:51

And that communicates with a portion or a slip of the cortical humeral

4:56

ligament. So, really interesting, uh, histologic and anatomic anatomy. And,

5:01

and I'd be happy to, uh, dig the, those reference for those that are interested.

5:06

But the important thing is,

5:07

anytime you have an intrasubstance or a del laminating tear,

5:11

you wanna describe that because, uh, in theory,

5:15

you wanna that or it's gonna be, uh,

5:19

arthroscopically occult. That is if, if you have an intrasubstance tear,

5:24

not in this case, because if you put in the scope, uh, on the articular side,

5:28

you should be able to see this tear, or the arthroscopist should be, uh,

5:33

uh, be able to see this tear from, from the, uh, uh, art, from the scope,

5:38

from the articular side.

5:39

But you can imagine if you have a hidden tear that is a arthroscopy,

5:44

arthroscopically occult tear that is purely intrasubstance or purely

5:49

intrasubstance with a delaminating component,

5:51

and let's say there's a intramuscular cyst,

5:54

if our arthroscopist puts their camera in either from the bursal side or

5:59

the articular side, that's gonna be that, that's not gonna be seen.

6:04

So that's why that's important. And the other thing too, um, uh, that,

6:09

um, you know, they, these, these, uh,

6:12

intrasubstance or delaminating tears,

6:15

they can sort of alize themselves and they

6:21

are more difficult to heal. Um, so that's probably the take home point,

6:26

uh, for this case. The other, uh, thing that I wanna highlight that came up,

6:31

uh, when I was grading, uh, the, uh, week five cases, uh,

6:36

I saw a lot of descriptive terms for this, uh, sort of artifact here.

6:40

And this is just a, uh, biceps tenodesis. Um, you know, and,

6:45

and if you were to, um, get a radiograph with this,

6:48

this would just look like a simple, uh,

6:51

loosen lesion at the proximal humeral diaphysis.

6:54

And the differential for that would be, uh, you know, a prior, uh,

6:59

probably calcium hydroxyapatite deposition with intracortical involvement of

7:03

the, one of the plate muscles. So we know that the pectoralis, um,

7:09

the Latissimus Dorsey and the, uh, Terry's major insert here,

7:14

okay, so it could be from that. And if you, if you guys, um, look up,

7:19

um, Linnie Steinbeck from radiology a a few years back,

7:24

she wrote about, or maybe it was an AJR,

7:26

she wrote about what's called the ring man's lesion.

7:29

So that's also on the differential there. If this person's older, um,

7:33

you know, uh,

7:34

one thing obviously for a loosened lesion you want to consider obviously are

7:37

gonna be Mets and myeloma. Those, uh,

7:39

would be on the differential if you were shown this, um, loosened lesion, say,

7:44

on a radiograph.

7:45

But those are probably the two main things that I wanna highlight on this case.