MRI shoulder: troubleshooting the cuff and instability. Phil Hughes Plymouth
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1 MRI shoulder: troubleshooting the cuff and instability Phil Hughes Plymouth
2 Shoulder Pathways Pain (subacromial/cuff) Stiffness (Frozen shoulder/oa) Weakness (Query cuff tear) Instability General Practice Conservative Mx Stop aggravating factors Analgesia Physio Blind Injection No response To injection General Practice Conservative Mx Analgesia Physiotherapy General practice Gross weakness Refer Ortho General Practice Uncertain diagnosis General Practice Physio Unable to inject or temporary response To injection ICAT 1 st or 2 nd injection ICAT (Ortho) ICAT (Ortho) ICAT (Ortho) Failed t injection <60 >60 XR Traumatic Atraumatic U/S guided Injection (up to 2 U/S guided injections) Fluoroscopy injection Candidate For SAD Adhesive casulitis Unresponsive to Injection No OA OA Failed Treatment Physio No Imaging Orthopaedics Orthopaedics Orthopaedics Imaging
3 Shoulder Pathways Pain (subacromial/cuff) General Practice Conservative Mx Stop aggravating factors Analgesia Physio Blind Injection Unable to inject or temporary response To injection ICAT 1 st or 2 nd injection Failed t injection No response To injection Primary Imaging Modalities Ultrasound MSI Plain films & US: Pre-op MRI: Problem solving U/S guided Injection (up to 2 U/S guided injections) Candidate For SAD Adhesive casulitis Unresponsive to Injection Orthopaedics Diagnostic US
4 Rotator Cuff
5 Rotator Cuff Tears Does MR have an Advantage? A C B D
6 Rotator Cuff Tears Full Thickness: Poor prognostic signs Medial Retraction Muscle Atrophy
7 Muscle Atrophy US v MRI RT Strobel. US in fatty atrophy of cuff muscles (2003) Accuracy 76-80% for grade 2-4
8 Rotator Cuff Injury Acute MRI preferable High performance individuals Professionals Normal US MRI
9 Rotator Cuff Tears Humeral head Stand-off
10 Case 1: 26 year old Policeman presented to ED following RTA: Driver in pursuit collision Severe Shoulder pain Weakness in abduction Immediate onset Failure to resolve over weeks Shoulder X-Ray Normal Provision Diagnosis Rotator cuff Injury
11 Coronal STIR and Proton Density Images
12 Sagittal STIR Images
13 Based on the MRI Imaging Most Likely Diagnosis? 1. Tendonopathy 2. Tear 3. Contusion 4. Neuropraxia 5. Quadrilateral Space Syndrome
14 Based on the MRI Imaging Most Likely Diagnosis? 1. Tendonopathy 2. Tear 3. Contusion 4. Neuropraxia 5. Quadrilateral Space Syndrome
15 Diagnosis: Suprascapular Neuropraxia Differential: C5 and/or C6 Nerve Injury
16 Muscle Denervation: Shoulder Suprascular Nerve Compression C5 C6 C7 C8 T1 Sup Trans Scap Lig SS Suprascapular Notch/Foramen IS TM
17 Infrascapular Nerve Compression Spinoglenoid notch cyst X X Suprascap Notch/Foramen Humeral Head Glenoid Differential Varix Stenosis at Foramen Trauma Posterior
18 Muscle Denervation Quadrilateral Space Syndrome IS TM
19
20 Case 2: 18 year old International High Board Diver 6 month history of shoulder pain Pain on flexion-abduction Nocturnal pain Recurrent
21 Coronal STIR Images
22 Sagittal Proton Density + Fat Suppression
23 Select the most likely diagnosis based on the MRI? 1. Bursitis 2. Tendonopathy 3. Tear 4. Os Acromiale 5. Superior labral tear anterior to posterior (SLAP)
24
25 2006 Jan
26 Os Acromiale Normal Appearances
27 Os Acromiale Incidence 1-15% Cadaveric 8% (33% Bilateral) Black:White 2:1 Sammarco et al, JBJS, April 2006 Jan
28
29 Case 3: 34 year old Royal Marine suffering multiple anterior shoulder dislocation First dislocation 3 years previous Now constantly apprehensive Downgraded No weakness
30 Investigating Instability Shoulder MR Arthrography v MR Advantages Spatial resolution Labral tears GHLs Rotator interval Partial RCTs Loose bodies Limitations Invasive Fluoroscopy Ultrasound Understand Surgical Requirements
31 MR Arthrogram: T1-SE + FS
32 Axial Proton Density with Fat Suppression
33 Coronal STIR Images
34 What Surgical Lesions Alter Management? Hill-Sachs lesion Size location Glenoid (Bony Bankart) Size attachments Labrum Varied tears Circumferential Humeral avulsion GHL (HAGL)
35 Hill-Sachs Lesion Left >30% Richards et al, Rad; 1994; 190: Right
36 Reversed Hill-Sach s Lesion and Multi-directional Instability
37 Bony Bankart Lesion Smaller lesions: Sutured with labrum Larger lesions: Open reduction Malunions: Liberated
38 1 Glenohumeral Ligaments Impact of Bony Bankart Lesion 3 2 4
39 Labral Tear Bankart lesion Classic Reattached Bankart
40 ALPSA: Chronic Anterior labral and periosteal sleeve avulsion
41 Sublabral Recess/Foramen Recess Foramen
42 Buford Complex Normal variant Differential: Bankart Lesion
43 Humeral Avulsion of Glenohumeral Ligament (HAGL)
44
45 Case 4: 39 year old male patient presented to Orthopaedic Surgeon with intermittent pain Fallen onto an outstretched arm Pain with resistance Pain on abduction Intermittent catching
46 Coronal STIR Images
47 Identify the correct diagnosis? A. Infraspinatus tear B. Metaphyseal marrow infiltrate C. Oedema in posterior deltoid D. SLAP lesion E. Avascular necrosis
48 SLAP lesions Superior Labral Anterior to Posterior Tear Mechanism Throwing Falling-Dislocation Clinical Evaluation Anatomy Technique MR v MRA
49 MRArthrography SSP ISP SSP ISP Neutral position External rotation
50 MRA technique Chan. SLAP lesions: MRA with arm traction AJR 1999; 173: 1117 Cor Obl T1W fat sat Cor Obl STIR Sag Obl T1W fat sat Axial Obl T1W fat sat Add Cor Obl T1W fat sat in external rotation Neutral External Rotation
51 SLAP lesions MRI v MRA % Sensitivity Specificity Accuracy MRI MRA Connell. Am J Sports Med 1999 Yoneda. J Shoulder Elbow Surg 1998 Bencardino. Radiology 2000 Jee. Radiology 2001 Waldt. AJR 2004 Reuss. J Shoulder Elbow Surg 2006
52 SLAP Lesion SLAP Type 3 Lesion STIR MR Arthrogram Monu et al, AJR, 1994; 163:
53 SLAP tears 1 2 Superior Labral Anterior to Posterior Tear Snyder. SLAP lesions Arthroscopy 1990; 6: 274
54 Extended SLAPS 6 SLAP 3 with flap tear 5 SLAP + anterior extension 8 SLAP + posterior extension 9 SLAP + anterior / posterior extension 7 SLAP + tear of middle glenohumeral ligament 10 SLAP + rotator cuff interval tear Mohana-Borges SLAP tear: classification and diagnosis AJR 2003;181:
55 SLAP 1 SLAP 2 Sub-labral recess
56 SLAP 2 Sub-labral recess
57 Other MR signs Double Oreo sign Tuite. SLAP lesions: 3 signs on MR. Radiology 2000
58 Recommendations for MRI Rotator cuff Elite sportsmen Atypical pain Unresponsive to treatment Instability No option (CT?) MR Arthrogram SLAP MR Arthrogram
59
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Clinical bottom line. For more detailed evidence on the effectiveness of injections for tennis elbow, please see the CAT on:
Short Question: Specific Question: In patients presenting with acute or chronic tendinopathies, what is the incidence of harm for those receiving steroid injections compared to those receiving usual care?