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So the history here was it was a shoulder MR examination,

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and the history was 52 year old male with right shoulder pain,

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slight limited range of motion, ongoing for three months, no history of injury.

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So here we have MR images. So we go to first review the axial.

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Uh, this is a PD fat set sequence and start from the

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cranial aspect. Uh,

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as we see we have the AC joint looks. Okay,

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then we have the acromion. So no, uh,

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variations in the morphology of the acromion, no acromial layer.

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These are the deltoid muscle fibers look fine. And this is your supraspinatus,

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uh, muscle and the tendon.

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And these are your infraspinatus fibers coming post from the posterior aspect.

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This is where they'll insert, this is the footprint.

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And we can see there is some heterogeneous signal at the footprint along the

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posterior supraspinatus and anterior and infraspinatus.

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There's some fluid signal. We see some fibers, so we'll look at other, uh,

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sequences to see what's going on there.

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As we more move more distally,

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we have some arrows here. This is your biceps tendon.

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So this biceps tendon is mely dislocated because this is the lesser

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tuberosity. This is the greater tuberosity,

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and this is the inter tuberculous groove, which is the bicipital groove. Uh,

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it becomes more prominent as we go, more distally.

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So this is the bicipital groove, and as we can see,

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the biceps has dislocated medially. So when di biceps dislocates medially,

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uh,

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it's usually happens because of tear of either it's a high grade tear of the

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subscapularis, but that's what we see in this case. Or there is, uh,

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a band of, or some fibers of subscapularis go over the lesser tuberosity,

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uh, to the greater tuberosity and form what is known as the transverse humeral

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ligament.

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So that is torn and that makes the biceps tendon unstable and it can

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dislocate, um, and displace medially as in this case.

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So we have a high grade partial articular sided tear of the subscapularis with

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tear of the transverse humeral ligaments.

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As we go more inferiorly, we can look at the glenohumeral joint.

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The labrum looks okay, articular cartilage looks fine.

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We still have this medially dislocated by biceps tendon,

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empty bicipital groove here. Okay,

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now let's move on to the other sequence for subscap. There.

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Sometimes they're harder to evaluate on, um, um,

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axial images. Um, so we can also look at sagittal images.

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We can start from the more medial aspect.

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This is your subscapularis muscle.

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That is the Y of the scapular that is supraspinatus.

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This is infraspinatus and this is T minor here.

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And we can see that sub subscapularis is a multi penate muscle.

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It has these multiple tendons, uh, and as, um,

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we come towards their insertion onto the tuberosity, towards the humerus. Um,

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you can see all these tendons coming closer.

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And here we see abnormal signal in the upper half of the tendon,

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which is fluid signal. And then it becomes complete, um,

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or near complete from the articular side. So it'll be a high grade, uh,

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at least a high grade, uh, articular side.

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Tear of subscapularis we keep on moving medially.

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And this is the, the, the footprint, the lesser tuberosity. On sagittal,

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I can see only the lower half is occupied by the tendon.

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The upper half is empty, uh, or there's just few fibers remaining.

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You have a high grade partial tear along the articular surface.

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There was another thing that was marked here, which was this.

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That is your intraarticular biceps tendon,

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which arises from the superior g glenoid here,

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and then it moves through the rotator interval.

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So rotator interval is between the subscapularis

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suppress.

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Spinatus is bounded superiorly by the coracohumeral ligament and inferiorly by

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the glenohumeral superior glenohumeral ligament.

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And then we can see this intraarticular biceps tend, is really thickened,

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has this really bright signal. So this is tendinosis,

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probably an interstitial tear.

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And as then it comes and because it has dislocated medially receded here

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rather than in the bicipital groove. And now it just goes, uh,

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distally in the arm. Let's look at the other tendons. So pressin we can follow.

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This is your, um, we can again go medial.

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Try to follow it from the muscle. This is your supraspinatus muscle.

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This is your in infraspinatus. That's the tendon. That's the tendon.

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As we go more laterally towards the footprint, um,

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the muscle volume will decrease and the amount of the tendon will increase.

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So as we go from medial to lateral side,

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we see it's getting more and more of tendon and less of muscle fibers.

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Looks okay here, but again,

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we lose some anterior most fibers of the supraspinatus at the footprint.

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And as we come here, again,

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it's not the normal appearance of the cuff tendon. Uh, it should be, uh,

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a thick band of, uh, T two dark signal,

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which is your normal rein tendon anteriorly and, uh, normal, uh,

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in infraspinatus tendon posteriorly here, the, the signal is all gray out,

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so it's tendinosis. And we lose some of the anterior most fibers of, um,

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rein and some fibers in the area of the conjoin tendon. Again,

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um, these things have to be looked in multiple planes. So now let's,

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let's look at the coronal image and see what the image shows.

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We can start from the interior.

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I think it went back. Okay, here's the anterior aspect.

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This is the cricoid process.

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You can see the short head of biceps arising from the cricoid process.

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And go back. This is your biceps tendon. As we can see, it's thickened.

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It has this entrance right signal. These are your subscapularis fibers.

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We can see it's, uh, that these fibers are torn.

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And we already determined from our cor axial and sagittal images that there is a

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highgrade partial articular sided there. This is your, uh, biceps tendon.

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As it turns, this is in the rotator interval.

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It'll go and insert onto the superior glenoid right there.

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But all along it goes, it has this really bright signal.

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So there is a big interstitial tear. We'll come to this again,

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but let's finish the tendons first. So right after the biceps tendon. But this,

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remember in this case it's dislocated medially,

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but you have to find the bpal groove, which is right here. And right after that,

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your greater tuberosity starts.

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So this is the anterior most part of the greater tuberosity.

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There are no normal tendon fibers coming and inserting.

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So here there is a focal full thickness tear of the supraspinatus.

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And you can see the stone retracted tendon, which is wavy.

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And as we go more posteriorly, it becomes like an articular sided tear here,

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almost like a very small tear remaining. But now we got majority of the tendon.

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And then as we come here, now we are in the conjoint tendon area.

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You start again getting an interstitial tear at the footprint.

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So these are called concealed interstitial delaminating tears.

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So if we have that tear in the region of conjoin tendon.

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And then these are the posterior, uh, infraspinatus fibers.

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And then this is tre minor, which is, okay. So cuff, we looked at cuff,

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we looked at biceps tendon, uh, findings. Uh,

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biceps tendon is medially dislocated. It has tendinosis,

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it has an interstitial tear. And then cuff,

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there's a high grade partial articular sided tear of subscapularis.

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Then we saw a small tear of the anterior supraspinatus,

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and then a concealed interstitial denominating tear of the conjoint and,

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and the footprint. Now starting, um,

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then we look at the labrum. So labrum, um, is at the periphery of the glenoid.

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It should be like a nice plaque triangle.

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It's a rim of fibrocartilage that surrounds the glenoid rim. Um,

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and the purpose of it is to deepen the glenoid cavity to provide stability to

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the joint. And this, since this is a piece of fibrocartilage,

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it should look dark on all pulse sequences.

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And it should be like a uniform black triangle. And as we can see here,

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uh, there is bright signal at the base of the labrum. Uh,

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and this is of inter intermediate signal intensity.

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And there's this signal that goes in the base of the labrum.

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So there is a superior labral tear that extends into the biceps. So, uh,

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superior labral tears. Uh, one of the, uh, acronyms that is used for it is, uh,

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slap tear, um, that stands for superior liberal anterior to posterior tears.

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And then there are several different types of slap tears described. Um,

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so the one which extends into the biceps tendon is your type four slap

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tear. So we have a type four slap tear here. Okay,

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let's finish up with other things.

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You have mild degeneration of the acromial clavicle joint here.

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Very important to look at the capsule, uh,

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because any abnormal signal in the capsule per capsular edema will suggest

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that these have capsulitis. Uh, we also look at the bone marrow signal.

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It's normal to have some islands of red marrow in the proximal humeral

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metaphysis.

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So all this bright thing that you're seeing in the marrow is just red marrow and

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that you can confirm by looking at the T one. So in the T one,

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if changes are not as hyperintense as the muscle,

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then it's probably just areas of red marrow. So, uh, marrow is fine.

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Um,

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coming back to the fluid sensitive sequences,

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uh, this will be your area of subacromial subdeltoid bursa,

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right underneath the acromial clavicle joint. And above the cuff,

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there's a little bit of fluid.

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So there will be mild that we'll call this as mild subacromial subdeltoid

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bursitis, there's no joint fusion. And then lastly, we'll look at,

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um, if the neurovascular bundle around the shoulder joint is okay. So, um,

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in the anterior most images, this is your suprascapular notch,

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which will have the subscapularis muscle.

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So no space co occupying lesion Here as we go more posteriorly,

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you get a little, uh, this deep notch, uh,

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that's your spinal glenoid notch.

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And this is still where your supine scapula nerve courses. Uh,

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but now it,

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it only supplies the in infraspinatus because it has already given its nerve

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supply to supraspinatus. So if you had any ganglion cyst here, uh, you'll see.

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And it's, if it's compressing the nerve, you'll see,

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you'll see the innovation changes only in the infraspinatus. I think that the,

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uh, these, these spaces are better evaluated on a non-fat side sequence.

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So I'll bring up a coronal T one,

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and then, yeah,

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you can see this fat and those vessels and nerves and that scapular notch.

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This is your spinal glenoid notch. And if you come more posteriorly,

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this is where your auxiliary, uh,

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quadrangular space containing auxiliary nervous.

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So not nothing focal there. So these were the main findings. In this case.

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You have subscap, uh,

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tear medial dislocation of biceps tendon rasin tear,

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a concealed interstitial delaminating tear of the conjoint tendon,

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then a tear of the superior labrum extending into the biceps anchor,

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no paralabral cysts. So again, uh,

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reviewing the anatomy, we briefly talked about this,

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that subscapularis is a multipennate muscle,

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this broad multiple tendons come in, insert onto the lesser tuberosity.

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And there then, uh, there are, uh,

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some fibers of subscapularis that cross over the lesser tuberosity to the

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greater tuberosity. And these form the transverse humeral ligaments.

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This is how it looks on mi imaging. This nice black tendon. Uh,

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this is a subscapularis. This anterior part is the lesser tuberosity.

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So that's the footprint of the subscapularis.

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And then you have the transverse humeral ligament that keeps the biceps tendon

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in place. Um, again, on coronal uh, images,

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you see the multiple tendons of the subscapularis.

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So when this sub either there is tear of the subscapularis or of the transverse

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humeral fibers, it, it, the,

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the biceps tendon loses its stability and it can dislocate, um, medially,

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um, within the tear or within the subscapular tendon.

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And then this is how your normal superior labrum should look like.

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A nice uniform, uh, hyperintense, uh,

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triangle with no abnormal signal at the base.

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And then our axial images are best to evaluate your anterior and posterior

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labrum. Nice again, black triangles. This is cartilage,

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no abnormal signal at the chondral labral junction. This is where most of your,

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uh, uh, tear start at the choral labral junction.

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So no signal abnormality there. These are just, again,

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examples of literature that show different forms of labral tears, um,

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in, in one image. So,

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so see that abnormal signal starting at the chondral labral junction, I'm sorry,

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extending into the base of the labrum. And here it goes, deep cutting, uh,

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undercutting the entire base of the labrum and then extending more medially.

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The same tears shown on Mr.

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Arthrogram see how the intra contrast imbibes within the tear

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and makes it more pronounced. And another.

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So this goes into the substance of the labrum and another superior labral tear,

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which goes all the way to the depth of the labrum and then extends medially.

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So this is how you look for superior labral tears.

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And as we said there of multiple, uh, there are several types.

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There are I think around 14, uh, subtypes of, uh, slap tears.

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The first four are important to know.

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Type one is where there's only only degeneration and freeing of the superior

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labrum.

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This would be a normal finding in anybody more than 50 years of age just because

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of repeated overuse of shoulder.

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And then type two is a discreet tear along the superior labrum.

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Now here we need to know how to differentiate a tear from atomic variations

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like sub labral sulcus of for rein. Uh,

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a tear is usually something that goes posterior to the biceps anchor.

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It has ratty regular margins and goes into the substance of the lab.

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Whereas any atomic variation is confined to the intra superior quadrant.

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The margins will be pretty smooth. It'll not go all the way into the,

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the base of the labrum and will not extend into the substance of the labrum.

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Then type three is a bucket handle tear of the superior labrum.

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Type four is a bucket handle tear that extends into the biceps tendon.

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And then five is when it extends into a ARD lesion. Four is when, uh,

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it is flipped, the torn fragment is flipped. Seven when it is going,

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goes into MGHL eight, when it goes into the posterior labrum.

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Nine is circumferential, so on and so forth. There are multiple,

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but I think it's the first four that can be identified and are important to

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know.

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Sorry, just a quick question. Yes. Um,

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the label tear in this case was described as bucket handle.

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Could you just review that? Yeah,

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I was happy that the labrum was torn, but I thought that it was undisplaced.

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Yeah, you see this when the labrum, uh,

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it's is this entire complex and it starts getting into the joint space here.

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And that's when we call it as a bucket handle. And also the,

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when it extends into the biceps tendon, it the, this part of the labrum,

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like it happens only when it like flips in like a bucket handle

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more inferiorly placed along the,

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within the joints. It's this part that extends inferiorly in the joint space.

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Oh, I see. That's inferiorly displaced there. So

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Yeah, this,

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this is the triangle where you have the biceps labral anchor and if there's a

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portion of the labrum that's extends inferior into the joint space,

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Thank

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You. These are harder. I mean, uh, but once you know it's a type four,

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you just automatically see a bucket handle. There.