Magnetic resonance imaging of the shoulder

Abstract

The aim of this article is to review the use of magnetic resonance imaging (MRI) for the evaluation of shoulder pain, which is a common clinical complaint of the musculoskeletal system. MRI is an essential auxiliary tool to evaluate these patients because of its high resolution and high sensitivity in depicting the soft tissues. This article will review the imaging technique, normal imaging anatomy, and most common imaging findings of disorders of tendons, labrum, and ligaments of the shoulder. It will also discuss common systemic diseases that manifest in the shoulder as well as disorders of the acromioclavicular joint and bursae. New advances and research in MRI have provided additional potential uses for evaluating shoulder derangements.

Keywords: MRI; acromioclavicular (AC) joint; glenohumeral joint; rotator cuff; shoulder.

Figure 1

Shoulder magnetic resonance imaging planes. A) Axial proton density-weighted fat-suppressed as well as (B) coronal oblique and (C) sagittal oblique T1-weighted magnetic resonance images of the shoulder show the typical positioning of the glenohumeral joint during the exam. The shoulder is in partial external rotation as seen by the position of the long head of the biceps tendon on the axial images (arrow). Correlation between axial, coronal oblique, and sagittal oblique planes are showed (inset images in B and C)

Figure 2

Tendinosis in a 45-year-old man with unilateral shoulder pain. Coronal proton density-weighted, fat-suppressed magnetic resonance image shows increased signal in the superior rotator cuff (arrow) without fluid gap, consistent with tendinopathy

Figure 3

Full-thickness cuff tear in a 50-year-old man with shoulder pain. A) Coronal oblique, proton density-weighted, fat-suppressed magnetic resonance image depicts a full-thickness tear of the superior cuff with retraction to the mid-humeral head (arrows). B) Arthroscopic image with scope in the subacromial-subdeltoid bursa shows the lateral bursal-side of the cuff (asterisk) with a direct intra-articular view of the humeral head (HH), long head of the biceps tendon (BT), and bare greater tuberosity (GT)

Figure 4

High-grade partial-thickness bursal-sided tear in a 53-year-old woman. A) Coronal oblique and B) sagittal oblique proton density-weighted fat-suppressed magnetic resonance images show a large bursal-sided tear (arrows) near the critical zone with medial delamination, associated with subacromial- subdeltoid bursitis. C) An intact articular-sided cuff was seen at arthroscopy (asterisk). D) Image with scope in the bursa confirms very high-grade bursal sided tear (arrows). HH – humeral head

Figure 5

Accentuated rotator cable due to a supraspinatus tear involving the crescent in a 41-year-old man. Sagittal proton density-weighted fat-suppressed magnetic resonance image shows a high-grade, partial- thickness articular-sided tear of the supraspinatus tendon with retraction, resulting in a thickened appearance of the rotator cable (arrow)

Figure 6

Delaminating tear of the infraspinatus tendon with differential retraction in a right shoulder of a 46-year-old man. A) Sagittal oblique and B) coronal oblique proton density-weighted, fat-suppressed magnetic resonance images show a tear of the infraspinatus predominantly involving the transverse portion of the layered tendon with retraction and surrounding muscular oedema (arrows)

Figure 7

Magnetic resonance (MR) arthrography demonstrating a high-grade, partial-thickness, articular-sided tear in a 30-year-old professional baseball player. A) Coronal oblique T2-weighted, fat-suppressed MR image shows a very high-grade tear of the supraspinatus tendon near the footprint (arrowhead) with a small amount of fluid in the subacromial-subdeltoid (SA-SD) bursa (arrows). B) Coronal oblique, T1-weighted, fat-suppressed MR arthrogram image shows an absence of fluid in the SA-SD bursa, confirming that the tear is partial-thickness rather than full-thickness

Figure 8

Internal impingement in a 30-year-old professional baseball pitcher with painful throwing. A) Axial T2-weighted, fat-suppressed magnetic resonance image shows posterior labral tear (arrow) and bone marrow oedema-like changes (arrowhead). B) Coronal oblique T2-weighted, fat-suppressed image show partial thickness articular-sided tear of the posterosuperior cuff (arrow) and bone marrow oedema-like changes (arrowhead)

Figure 9

Inferior subscapularis myotendinous junction strain in a 22-year-old pitcher with acute posterior shoulder pain. A) Axial and B) sagittal oblique, proton density-weighted, fat-suppressed magnetic resonance images show oedema centred around the myotendinous junction of the inferior subscapularis muscle (asterisk), consistent with a grade 2 strain

Figure 10

Calcium hydroxyapatite crystal deposition in the superior cuff in a 67-year-old woman. A) Coronal oblique, T2-weighted, fat-suppressed magnetic resonance image shows a large, hypointense deposit in the supraspinatus tendon with surrounding oedema (arrow). B) Arthroscopic image shows the bursal surface of the rotator cuff during expression of the calcium hydroxyapatite crystals from the cuff tendon

Figure 11

Paralabral ganglion cyst. T2-weighted, fat-suppressed magnetic resonance images in the A axial and B sagittal oblique planes show a posterosuperior labral tear (arrow) with a lobulated paralabral ganglion cyst extending through the suprascapular and spinoglenoid notches. No muscle signal alteration is present to suggest suprascapular neuropathy

Figure 12

Superior labral variations in a 28-year-old woman (A) and a 42-year-old woman (B, C). A) Coronal oblique, T1-weighted magnetic resonance (MR) image shows a meniscoid-type superior labrum. B) Coronal oblique, proton density-weighted, fat-suppressed MR and C) arthroscopic images show an intact bumper-type labrum (arrowheads). G – glenoid, HH – humeral head

Figure 13

Labral variations in an 18-year-old man (A, B) and 48-year-old woman (C, D). A) Coronal oblique, T1-weighted, fat-sup pressed magnetic resonance (MR) arthrography image shows a sublabral recess (arrow). B) At arthroscopy, the superior labrum was stable to probing and a small recess was confirmed (arrow). C) Axial proton density-weighted, fat-suppressed MR image shows a sublabral foramen (arrowhead). D) Arthroscopic image shows a meniscoid-type superior labrum (L) and a sublabral foramen (arrowhead) at the level of the glenoid notch. G – glenoid, HH – humeral head

Figure 14

Buford variant in a 22-year-old man. A) Axial T2-weighted, fat-suppressed magnetic resonance image shows an absent anterosuperior glenoid labrum and thickened middle glenohumeral ligament (MGHL) (arrow). B) Arthroscopic image confirms the absent labrum along the anterosuperior glenoid (G) and thickened MGHL deep to the subscapularis tendon (asterisk)

Figure 15

Seizure-induced posterior shoulder dislocation in a 42-year-old man. A) 3D volume-rendered image from computed tomography exam shows a posterior dislocation with comminuted fracture of the proximal humerus. B) Axial ZTE magnetic resonance image post-reduction confirms normal glenohumeral alignment and the comminuted fracture of the proximal humerus (arrow). The lesser tuberosity fragments have been termed the “veil of obscuration”, which is a helpful radiographic sign of posterior dislocation

Figure 16

Magnetic resonance (MR) imaging with computed tomography-like contrast in a 48-year-old woman with chronic glenohumeral joint dislocations (A, B) and a shoulder specimen (C, D). 0.8 mm3 isotropic ZTE dataset obtained in 8 minutes scan time allows for multi-planar reconstruction in the (A) axial and (B) coronal oblique planes, and visualisation of a Bankart fracture with small adjacent fragments (arrow) and a Hill-Sachs lesion (arrowhead). IR-UTE MR images in the (A) coronal and (B) sagittal oblique planes show high-contrast bone images with excellent soft tissue suppression

Figure 17

Humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion in a 27-year-old professional pitcher (A-C). A) Coronal oblique and B) ABER T1-weighted, fat-suppressed magnetic resonance arthrogram images show a torn, retracted, and scarred anterior band of the inferior glenohumeral ligament (arrows) with extra-articular contrast extravasation. C) Arthroscopic image confirms the HAGL lesion with the retracted and scarred margin (arrow) and surrounding inflammation. D) Arthroscopic image of an intact IGHL in a 22-year-old for comparison

Figure 18

Posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion in a 17-year-old with shoulder dislocation during wrestling match. A) Coronal and B) sagittal oblique, non-contrast, T2-weighted, fat-suppressed MR images show a torn and retracted posterior band of the IGHL (arrows). The anterior band is intact (arrowhead). C) Sagittal, oblique, proton density-weighted, fat-suppressed MR image after intra-articular injection of contrast, obtained 1 month after the non-contrast exam, confirms the intact anterior band (arrowhead) and torn, retracted, and scarred posterior band of the IGHL (arrow). D) Arthroscopic image shows the torn margin of the posterior band (arrow) with the rotator cuff muscle visible posteriorly through the defect (asterisk). E) Arthroscopic image shows the repaired IGHL complex using sutures and an anchor. HH – humeral head

Figure 19

Superior labrum anterior-posterior (SLAP) tear in a 22-year-old professional baseball pitcher with shoulder pain. A) Coronal oblique, T1-weighted, fat-suppressed magnetic resonance arthrography image shows contrast extending into the labral substance, consistent with a SLAP tear. B, C) Arthroscopic images show the unstable, detached superior labrum (asterisk) being uplifted by the probe. G – glenoid

Figure 20

Adhesive capsulitis of the shoulder. A) Coronal oblique, T2-weighted, fat-suppressed magnetic resonance image shows massively thickened and oedematous inferior glenohumeral ligament (IGHL) complex (arrow). B) Arthroscopic image confirms synovitis in the rotator interval (arrowhead). SSCT – subscapularis tendon

Figure 21

Geyser signs in a 56-year-old man (A) and a 62-year-old man status post cuff repair (B, C). A) Coronal oblique, T1-weighted, fat-suppressed magnetic resonance image post intra-articular contrast administration shows a retracted, full-thickness superior cuff tear (thick arrow) with contrast extending into the AC joint (thin arrow). B) Coronal oblique computed tomography (CT) arthrogram image shows contrast extending through tears of the superior cuff and inferior AC joint capsule (thick arrow), and into the trapezius muscle belly (arrowhead). C) 3D CT maximum intensity projection image shows the full extent of the ganglion cyst. An external marker was used to delineate the mass the patient was feeling