1. MR Imaging of the Rotator Cuff
Timothy G. Sanders, M.D.

2. MRI Technique -T1 and T2 FS -Oblique Coronal -T1 and T2 FS
-Oblique Sagittal
-T2 FS and GRE
-Axial

3. Osseous Outlet and Acromion
Rotator Cuff Surrounded by a Bony Arch
Mechanical Impingement leads to degeneration of the cuff
Anterior Acromion Most Important Structure Leading to Impingement

6. Normal Osseous Outlet
Clavicle
Acromion
Coracoid

8. Acromial Types
Type I

9. Acromial Types
Type II

10. Acromial Types
Type III

11. Acromial Types
Type IV

12. Acromial Down Sloping
Anterior Down Sloping Evaluated on Sagittal Images
Axis of Acromion
Normal Axis of Acromion
Anterior Down Sloping

13. Acromial Down Sloping Lateral Down Sloping Evaluated on Coronal Images
Axis of Acromion
Normal Axis of Acromion
Lateral Down Sloping

14. Acromial Spur -Spur -Contains Marrow Signal
-Deltoid Tendon (Mimics Spur)
-Black (No Marrow Signal)

15. Os Acromiale

16. Os Acromiale Ossification Center Usually Closes by 22-25 y.o.
Normal Appearing Anterior Acromion on Axial Image

17. Os Acromiale (Axial Images)
-Can be unstable resulting in impingement of Rotator Cuff during contraction of the deltoid

18. Os Acromiale (Sagittal Images)
Normal AC Joint
“Double” AC Joint Sign

19. Os Acromiale
AC Joint
Os Acromiale
“Double” AC Joint

20. Acromion Type (I, II, III) Anterior/ Lateral Down Sloping
Inferior Spur
Os Acromiale

21. Coracoacromial Ligament
-Thick Ligament can Impinge on Anterior Rotator Cuff
-Normal Ligament <3 mm

22. Acromioclavicular Joint
-Does it cause mass effect on rotator cuff?
-AC degenerative change, capsular hypertrophy
-Cuff less rigidly confined

23. AC Joint Sprain/Separation
Grade I
-Capsular edema, effusion
-No elevation
Grade II
-Capsular edema, effusion
-Elevation distal clavicle

24. Osteolysis of Distal Clavicle
Post-traumatic osteolysis
-Complication of trauma (occurs within 2 months of injury, self limiting)
-Repetitive stress (wt. lifters)
-X-ray: loss of normal cortical line- distal clavicle

25. Coracoid Impingement
-Narrowed C-H Distance can Impinge on Subscapularis
-Normal Coracohumeral Distance is 11 mm

26. Osseous Outlet and Acromion
Type, Down Sloping, Spur, Os Acromiale
AC Joint
Deg. Change, Hypertrophy (mass effect?)
Coracoacromial Ligament (thickened?)
Coracohumeral Impingement (subscap?)

27. Rotator Cuff (Sagittal)
Supraspinatus;
Infraspinatus;
Teres Minor;
Subscapularis

28. Rotator Cuff (Coronal)
-Primary Plane for Evaluating the Supraspinatus Tendon
-Musculotendinous Junction at 12:00 Position

29. Rotator Cuff (Axial Plane)
-Supraspinatus Tendon

30. Rotator Cuff (Axial Plane)
-Primary Plane for Evaluating Subscapularis
-Infraspinatus
Located Posteriorly

31. Rotator Cuff (Coronal)
-Subscapularis
- Located Anteriorly
- Multi-slip tendon
- Infraspinatus
- Located Posteriorly
- Slopes upward

32. Rotator Cuff Pathology
Tendonopathy
Tear
Partial Thickness, Full Thickness, Complete
Musculotendinous Retraction
Fatty Atrophy
HADD/ Calcific Tendonitis

33. Tendonopathy
-Increased T1-signal; thickened/ attritional changes (thinned)
-Intermediate T2-signal (No Fluid Signal)

34. Partial Thickness Tear (Articular)
-T2: Fluid Signal extending into black tendon
-Partial Thickness Undersurface Tear

35. Partial Thickness Tear (Bursal)
-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Tendon

36. Partial Thickness Tear (Interstitial)
-Fluid Signal within the Substance of the Tendon
-Does Not Involve the Articular or Bursal Surface

37. Intramuscular Cyst Rotator Cuff
-High Association with
1. P.T. Undersurface Tear
2. Small F.T. Tear
3. DDX: Paralabral Cyst

38. Intramuscular Cyst Rotator Cuff
-Intramuscular Cyst Supraspinatus
-Small Undersurface P.T. Tear

39. Delamination (retraction of deep fibers)

40. Full Thickness Tear
-Fluid extends through the entire thickness of the tendon (superior to inferior)
-Mild retraction of musculotendinous junction

41. Musculotendinous retraction
Massive Tear
Musculotendinous retraction
-Measure in centimeters; can affect prognosis

42. Fatty Atrophy -Mild, Moderate, Severe -Streaks of high signal on T1
-Loss of muscle bulk (Sagittal)

43. Calcific Tendonitis -HADD: Dark Globular Area on all Pulse Sequences
-Blooming Artifact on Gradient Echo Images

44. Subscapularis -Subscapularis: Attaches to lesser tuberosity
-Extra-articular Biceps: Best Seen on Axial Image
-In Bicipital Groove; Transverse Ligament

45. Avulsion of Subscapularis
-Subscapularis Muscle can Avulse off of Lesser Tuberosity
-Associated with Dislocation of the Biceps Tendon
-Seen best in Axial Plane

46. Biceps Tendon (Anatomy)
CH Ligament
Biceps Tendon (Anatomy)
LHBT
LHBT
Coracohumeral ligament primary stabilizer of LHBT

47. Biceps Tendonitis/ Tear
-Thick Tendon; Increased Signal
-Intra-articular
-Extra-articular

48. Biceps Tendon (Anatomy)
Subscapularis/ transverse humeral ligament
Secondary stabilizer

49. Biceps Subluxation: Pattern I
CHL: intact
2. Subscapularis tendon: complete tear
- No Dislocation of LHBT

50. Pattern II: Intra-articular
CHL: torn
Subscapularis tendon: complete tear
- Intra-articular dislocation of LHBT

51. Pattern III: Extra-articular
CHL: torn
Subscapularis tendon: superficial fibers torn
-Extra-articular dislocation of LHBT

52. Pattern IV: Interstitial
CHL: torn
2. Subscapularis tendon: intact
- Subluxation of LHBT into substance of subscapularis tendon and muscle: interstitial tear

53. Rotator Cuff Pathology
Tendonopathy
Tear
Partial Thickness, Full Thickness, Complete
Musculotendinous Retraction
Fatty Atrophy
HADD/ Calcific Tendonitis
Nerve Entrapment Syndromes