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Rotator Cuff Anatomy and Imaging

Sep 26 | 6:00 AM

Diagnostic imaging of the rotator cuff provides valuable information with regard to the anatomical extent of tears & involvement of specific soft tissues or structures or pathological changes involving the rotator cuff muscles. Having Knowledge of this is important because it may affect therapeutic decision making, surgical planning and post surgical prognosis. Let’s get more insights and better understanding into the imaging of rotator cuff with Dr. Varun Kumar Sehrawat.

[Music] a very good morning to everyone uh present here i'm dr naveda from netflix and on behalf of team netflix i would i welcome you all to today's session on rotator cuff anatomy and imaging by dr varun kumar serapha dr varun is working as a radiologist at dr babasa bambedkar hospital new delhi he's an ames bhopal graduate and very passionate about teaching and he strives to keep himself updated in his field by constantly learning about new methods good morning everyone my dear seniors colleagues juniors welcome to this small and interesting session on basic shoulder joint and acne as well as basically the rotator cuff imaging on ultrasound as well as on mri so let's begin this session so here we can see basically we have the bony anatomy and the muscular soft tissue part that is muscles shoulder joint is formed by the glenoid cavity and the head of the humerus superiorly we have acromioclavicular giant and anteriorly we have coracoid process enteromedially we have coracoid process and on the muscular part we have a rotator cuff muscles around the shoulder joint which is comprised of the things we will see before going to further into the rotator cuff first i'll suggest because patient will come to us for his shoulder pain it is not always like patient is having muscle pain so we should always cut get a uh x-ray done both in ap as well as uh scapular v or yv so this is normal uh ap view of shoulder joint which is which you can see on the screen we have uh the shoulder giant head of the humerus as uh forming uh joint with the glenoid cavity so we have the normal shoulder joint and the typical finding we see that part of the head of the humerus will cover the posterior aspect of the glenoid cavity so it will form uh overlapped half moon sign so if it is present then you can be sure of and there is maintained uh glenohumeral joint uh distance so we can say we have the normal joint anatomy these are the colors colors we have put the blue one is the head of the humerus red one is the glenoid cavity purple is the distal end of clavicle and the green forms the acromion process which form the acromioclavicular joint above and the main shoulder joint glenohumeral joint below now this is the lateral view that is called y view in and this one the head of humerus occupies or overlapped the glenoid cavity which which we can see on the left side we have the normal joint and it is depicted in the left side of the images as we can see the red one which is within the area of head of humerus that is glenoid cavity and the structure covering this whole red red part is the head of humerus anteriorly we have coracoid pros uh corrugated process and the posteriorly green portion is the uh green portion is acromion which is articulating with the discipline of clavicle which is denoted by the purple color which forms the acromioclavicular joint now these these thing we should always remember how to say there is some dislocation or effusion within the shoulder joint so there is some cut offs are seniors have decided so we have acromioclavicular distance between the acromion process and clavicle if it is more than 8 mm we can say there is some discrepancy in between acromioclavicular joint and another one is the acromial coracoclavicular distance that is denoted by number two in the image which is uh so superiorly we have clavicular bone this land of clavicle and clearly we have inferiorly we have paracord process so if it is dislocated if there is fracture of discipline of clavicle or fracture of uh coracoid process if there is increase in the distance we can say uh that there is some discrepancy in the coracoclavicular area so if there is injury to the coracoclavicular ligaments that also will leads to increases this in this distance acromio humeral distance superiorly we have a acromion process inferiorly we have head of humerus so if as we know uh the supraspinatus muscle usually attach on the greater tuberosity which will study later on also so there is distance but there is some gap between acromion process as well as ah head of humerus so that gap is filled with um by the acromioclavicular arch as well as subacromials sub deltoid bursa as well as supraspinatus muscle and inferior most and attaching to the head of humerus we have capsule so if there won't be any supraspinatus muscle or there is complete tear of supraspinatus muscle and there is a retraction of the fibers you won't see supraspinatus muscle in between this joint and this distance acromion distance so this distance will decrease that is if it is less than 7 mm then we can think of possibility of supraspinatus tendon tear that will be totally complete uh complete full thickness uh supraspinatus tear and if it is increased that is more than 12 mm it suggests there is joint diffusion or joint whitening now we will see the muscular part or the soft tissue soft tissue part around the shoulder joint this is the lateral view in the next slide we will see interior view this is a lateral view on right side right hand side of the images we have the interior aspect and the on the left side we have posterior aspects so anterior will have coracoid process posterior we have acromion process and the structure in the middle you are seeing that is glenoid cavity and the structure which is highlighted or light it is the glenoid labrum as we know this shoulder joint is a box and socket variety of synovial joint and this is the most this is complex joint as well as more mostly rotatable or movable joint so this joint is this is the flattened surface the glenoid is a bit flattened and the the depth is increased by this glenoid cavita glenoid labrum so it will deepen the structure deepen the glenoid cavity and there will be more movement around the shoulder joint so anteriorly we have like on the muscular part we have anteriorly subscapularis muscle posteriorly we have posterior superiorly we have supraspinatus inferior to supraspinatus we have infraspinatus and below that we have teres minor other than that we have ligaments around the shoulder joint also like correct acromial ligament acromioclavicular ligament then transverse humeral ligament and this in this structure we have mentioned uh superior the glenohumeral ligaments we have mainly three types of uh glenohumeral ligament that is superior inferior superior middle and inferior on inferior aspect we have uh anterior inferior grenade hemorrhoid ligament and the posterior inferior glenohumeral ligament these all these structures give stability to this shoulder joint basically we have the shoulder joint is covered all over them but on the inferior aspect we don't have proper muscle but that's why it is there is lack of support on the inferior aspect that's why there is more chances of dislocation on the inferior aspect normally we see shoulder in shoulder joint reach the anterior disc locations most commonly and in anterior dislocation also because there is a lack of support on the inferior aspect so most commonly the displacement will be or subluxation will be entero inferior now this is the anterior view we can see the subscapularis muscle coming from the scapular fossa and attaching attaching to the attaching to the lesser tuberosity as you can see we we have the muscle which we go for gem like making the body uh bodybuilding and all that is biceps so in biceps we have two heads long head and short head in long hair that is covered by and supported by supra subscapularis muscle and this long head of biceps present within the bicipital group or intertubal tubercular group that is between the greater tuberosity and lesser tuberosity and this is the posterior view as the name suggests we have supraspinatus infraspinatus so there should be something which is above the spine that is scapular spine as we can see in this one we have the spine of scapula so structure above the spine of scapula is supra spinatus muscle and inferior to the spine of scapula we have infraspinatus muscle and below that we have teres minor and both of these force muscles that is subscapularis anteriorly then supraspinatus infraspinatus and teres minor form rotator cuff around the shoulder joint and for interpretation of as we have seen the normal joint shoulder joint x-ray we should comment what should we comment on normal shoulder joint we should see the alignment first whether the there's proper alignment of acromiomeral uh joint glenohumeral joint and this one clavicle acromioclavicular joint so other than the alignment we should see the bones whether there is an any anomaly any lesion any fracture of the bone is there and later on soft tissue whether because of trauma there is lipohemoarthrosis there is abnormal soft tissue density around the shoulder joint and the last but not but not the least we should also see the medial aspect of shoulder joint that is involving the pectoral gradle that is girdle that is ribs and lungs also so now we should we will discuss little about shoulder dislocations we have anterior posterior inferior dislocation nta1 are the most common and in that also so shoulder and shoulder dislocation anterior shoulder dislocation are the most common shoulder dislocation in anterior also we'll see entero inferior so this is the ap view here we can see there is this articulation and subluxation of humeral head from the glenoid fossa and it is it has came into interior and the medial aspect inferior and medial aspect so this is anterior shoulder dislocation we should always always get the lateral view of shoulder joint to say anterior and posterior dislocation because they can be confused so in lateral view we'll see the head humeral head is displaced anteriorly and inferiorly so now we are sure that we have anterior shoulder dislocation now we'll progress to posterior shoulder dislocation that's the first image i have put that is before the relocation that is after dislocation of shoulder joint so we can see we are not able to see proper contour of humeral head along along with the adjacent glenoid cavity so the next slide here you can see the proper alignment of the humeral head with the glenoid cavity that is after relocation of shoulder joint so what sine with typical say in posterior dislocation is that is light bulb sign as you can see on the inferior inferior mirror uh there is like we have drawn one bulb with a filament inside that is light bulb sign seen in posterior view here we can't see proper contour of humeral head and because of rotation and posterior dislocation we'll see this sign now other than the dislocation we can have we'll see bones we can have fracture of the fractures of the bone in case of rtas and injuries like then in these view on the left side we are seeing there is this fracture of left clavicle on the right images we we can see there is combinated fracture of humeral head so we should always see uh shoulder joint as well the adjacent bone we should always always see adjacent rib fracture properly because if there is the fracture and there is conclusion lung contusion and if there is a puncture of the lung puncture of the pleura they can be pneumothorax we should always see the adjacent structure around the shoulder joint in case especially in cases of rta now the soft tissue as this in this picture we have calcified supraspinatus tendon that is calcified tendinosis because there is deposition of calcium hydroxyapatite hdd in this tendon so we can see on x-ray as well as on ultrasound we will see multiple hyperechoic foci with or without casting pas within the digital aspect of supraspinatus muscle this is common site for calcification in rotator cuff now to mention that we should also see the adjacent structures here we have ill-defined heterogeneous radiopasty noted in the left up left upper lung zone this case was pancos tumor so we should always always see the adjacent structures now why we should now we'll see the anatomy of rotator cuffs rotate off muscles on ultrasound and mri so why we should go for ultrasound why can't we go directly for mri because mri will have greater resolution better imaging the reason is on ultrasound it is first is cost effective easily accessible and no no use of any contrast material or anything and it takes less time than mri so if we if i'll tell about the sensitivity of the ultrasound for rotator cuff tear it is high in cases of full thickness tier sorry it is written as delt thicknessed here it is complete full thickness tier and it is 85 for partial thickness rotator cuff tier so there is fixed protocol for shoulder joint ultrasound uh evaluation so initially we will see usually uh if i am sitting like this if radiologist is examining me so the pro pro will be like first we have five positions to see properly see the shoulder joint we have in first position we will see bicep brachii long header long head and short and short axis view like in ultrasound if i'll say uh as i had done the ultrasound of shoulder joint we should always see every muscle properly and in both the views short axis view as well as long axis view till from its origin to its insertion if possible and insertion should be always seen properly so initially you will see biceps precare then subscapularis biceps bicep brachii tendon and third we'll see supraspinatus and rotator interval and then fourth we will see joint acromioclavicular joint and bursa and will do the dynamic evaluation like live evaluation for shoulder infringement like subacromial impingement and last but not the least we will see infraspinatus theories minor as we will see the bony and bony and the articulation of muscles on the bones so we will we have the biceps brachii anteriorly we have biceps brachii tendon short head and long head short long head arranged from supraglenoid area so and the shortest short head arise from uh coracoid process so along with that we have uh subscapularis muscle arising from subscapular fossa to the lecithin prostate on the inferior aspect as you can see we have supraspinatus infraspinatus muscle as we have already discussed the rotator cuff muscle that is supraspinatus intraspinatus subscapular series minor as you can see all of them on this view also now this is one by one uh muscle uh i have depicted like the first one is long head of biceps brachet and then the second one is short head or biceps brachii on the left left lower side we have subscapularis muscle anteriorly and in the middle one we have supraspinatus muscle arising from supraspinatus fossa and attaching to the superior aspect of greater tuberosity and on the posterior aspect as it is coming from the posterior we can see the bulk of the bulk of the supraspinatus muscle and it is going inferior to the acromion process this this is the typical we should always have in mind the supraspinatus muscle is coming from the posterior side and it is crossing uh under the acromion process and getting attached to the um shoulder joint on the greater tuberosity so that is important we will see when we will see the dynamic evaluation of uh subscapularis muscle impingement or subacromial impingement in that part we have to see if if i'll think of this is the acromion process and this is the shoulder joint if i'll ask the i'll ask patient to abduct the shoulder so the greater degrassi gt should go under the this under the acromion process normally it should go smoothly if it's not going if something is obstructing here it can be tear it can be calcif calcification it can be like subacromial bursitis so it won't go smoothly under the acromion process that suggests subacromial impingement that we will study in one video later this is the posterior view for supraspinatus infraspinatus and teres minor muscle and before going further i'll i want to convey one uh simple message that while evaluating a tendon like usually we take supraspinatus tendon the tendon have two sides like first one is the inferior as you can see in the image near to the head of the humerus that is blue structure that is cartilage that is called articular side of tendon and superiorly we have subacromial seb deltoid bursa so the superior aspect is called bursal side of the tendon so that is typically that is important in cases of partial thickness rotator cuff muscle injuries so as i have shown the shoulder protocol these are the four four four positions you should in which you should see the shoulder ultrasound and the muscles first one is you will ask patient to uh just relax and put his arm over the thigh and and second second view first view is for biceps brachii tendon that the doctor is radiologist is uh scanning the biceps brachii in short axis view as you rotate the 90 degree you will get the long axis view second one is for subscapularis just what you have to do just put the probe from the lateral aspect to the medial aspect you will see subscapular standard and the the motion in the second one the patient is doing mild uh external rotation so the rotation external rotation and internal rotation will see the movement of the subscapularis tendon and the third one we'll ask the patient to put his arm into the pocket pocket back so that is to make the this shoulder joint to make the greater tuberosity anteriorly so the our supraspinatus tendon will be taut will be stretched out so we can better see the supra spinous tendon the third one is for evaluation of infraspinatus tendon and theories minor because in that one we'll properly see the infraspinatus and these minor muscles so just for the interpretation what we see on ultrasound initial the superior most we have skin and subcutaneous tissue then fiber deltoid sorry deterred fibers then we have bursa subacromial subdelta adversa and inferiorly we have tendon then articular surface cartilage and this the structure of attachment of the tendon to the bone that is called footprint footprint of the tendon we should we should clearly see that the whole tendon is normal or not the attachment is on normal or not because that is important in cases of intra substance tear because there will be multiple hypoechoic areas or any quick areas noted will be seen in cases of intra spinous intra substance tier however the tendon attachment will be there but there will be multiple hypoechoic areas or any quick areas will be there near to the attachment side or within the substance of the muscle now this is step by step depiction of the steps we have seen in the first step we are seeing the short head of long enough biceps pre-k and you can see the bicipital groove and there is long enough biceps break basis brachii present within the specific group and if i'll rotate the probe 90 degree will see this long adder on this long axis view of biceps bracket so every muscle we should see uh short axis in short axis view as well in as as well as in longest view now this is just put the probe medially you will see the supra spineless tendon a smooth uh crease and shaped curvilinear uh shape uh structure present adjacent to the this one head of the humerus then this is uh subscapularis tendon and what i said is just ask the patient to move hand from uh for like internal rotation and external rotation you will see you the motion of the subscapularis tendon then this is supraspinatus tendon pocket view like as you can see there is on in the pictorial view in the picture we we we can see the bony structure casting pas that is acromion process and the head of the humerus and there is insertion of the supraspinatus muscle that is uh tendon as well as the footprint of the supraspinatus tendon so as you can see in the image on the on your right side there that is acromion process and on the left side that is head of the humerus i ask patient to just abduct the shoulder literally so what it will do that i have shown also the head of the humerus will go under the acromion process normally if it is normal if there is impingement if there is impingement then it will be restricted and this i have tried to show bicipital groove with biceps tendon within and on the right side on the right side you can see the muscle tendon that is subscapularis i think everyone can see properly and now i have asked patient to external rotate and interrotate the arm so that i can see properly the subscapularis muscle and the structure you are seeing here the small hyperechoic casting pas that is bone that is coracoid process so it is going under the coracoid process and due to the motion we can see the subscapularis tendon okay i think everyone saw this and you should practice uh shoulder joint ultrasound at your centers or classes or you should be perfect in doing ultrasound of shoulder joint also and this is supraspinatus we have done and this is the uh imaging for infraspinous muscle in this one we can see the infraspinatus muscle uh and the tendon later on uh over the head of the humerus and above it there is that is sub acromial fat and above that that is a chromium process now the pathology of rotator cuff tendons we see tendinopathy tendonopathy and the tears in tears we have partial tear and complete tears and partial tear we have like i have told we have two sides of tendon that is versus articular side on the near to the head of the humerus and the bursts are side near to the uh economic process or superiority near the bursa so we have ah burster side and uh articular side so in partial tier we can have buzzer side partial tear and as well as capsulars like bustle and articular side partial tear in case of complete thickness here we have a full thickness here and there are few uh classifications uh like seeger and carino seeger divided tears based on mri only they have divided tears based on mri into three types type one and type one two and three and carry in your divide that is extended uh uh explanation is that uh from the carinio now he divided the tier into seven types like particularly uh tendinitis and then degeneration then t year first initially partial tier then uh partial tier with then complete year then complete year with intact fibers comp complete here with the few retained fibers and totally complete uh full thickness tier with retracted fibers so there are total seven type of like rotator cuff tier uh like imaging from the kerino you can see here on the image internet also for tendinopathy they we can have first of all in muscle everyone know that there is february pattern uh by which we diagnose that we are seeing the muscle in tendinopathy there will be loss of febrilly pattern and there will be thickening of the muscle tendon so here we can see the tendon thickening and also loss of febrile pattern other than that we can see if there is uh this is chronic nanopathy we can see calcification within the tendon that is calcified pacific tendinopathy in rotator cuff as i have already told in partial thickness we can have articular surface article surface tier versus sulfate tear or intra substance and in full thickness here there will be complete complete tear from the bursal side to the articular side so only in those cases we should give full thickness complete here in partial tears as this is the imaging finding in case of in first images first image you can see there is hyperechogenicity and hypo to any quick uh areas no area noted near to the articular surface with intact versal side of the tendon so this is articular side articular side partial tear on the on second view we can see there is tear or any hypoechogenicity on the versa side with intact articular side so here we will see we will say that is burst side partial tier in this one there will there are multiple areas hyper equivalent to any quick areas noted within the substance of tendon with proper attachment near total proper attachment to the head of humerus that is inter substance a partial tear now this is here we can see there is total any uh hypo equations to an anechoic areas noted adjacent to the head of humerus that is there is no tendon attached to the greater tuberosity that is supraspinatus and no tenor attachment so we can say this is complete thickness tear complete full thickness here or in the inferior aspect we can see the hyperechoic retracted fibers of subscapularis muscle now as we have already seen ultrasound of shoulder joint now we will move on to mri because we can get if we have time monetary aspect if everything is fine better to go for mri if you have suspicion on ultrasound to confirm that suspicion whether we are correct or not you can go for mri so pdf is the best sequence to see anatomy and it's it's like victim you should see every section every uh image properly to see the muscle uh the belly and the tendon part for from the shoulder joint as we already know we all know from our um vidi character first year anatomy that our shoulder joint is not properly anterior posterior it is bit bit uh like anteriorly so in in every joint we what we do we take three localizers anterior post anterior like um what core of course edge and axial view so what we will do in this shoulder joint will take the coronal sections axial we can take properly normally but the planning after the localizer it will be oblique sections so what what should be the uh angle what should be the plane our plane should be along the supraspinatus muscle and tendon so this will be the plane for planning so what we will do we will take axial pdfs view suggested view suggested specifically search for oblique then core oblique and t1 and with t2 will put a fair suppression after this and especially especially we should always always put medicaid to star medic view or gr review to see any calcification within the rotator cuff tendons this is the plane of uh where we should plan if we are planning core oblique this is the plane okay if we want to plan search oblique we'll just put perpendicular to this plane sections perpendicular to this plane now just for the mri picturization this is supraspinatus tendon muscular anatomy and on the medial on the inferior view we can see the tendon and the footprint of supraspinatus muscle as you can see it is attaching to the greater tuberosity this is the tendon of the supraspinatus muscle so we have seen anterior view this is little view on lateral view we can see in mri we do not have lateral view per se we have a subjective view so this will be called as a zetal view so instead of you will see above the spine of scapula you will see supraspinatus then in fairly we will see infraspinatus that is towards the media respect on the lateral aspect we will go we'll see the teres minor muscles muscle belly also and the anterior to the scapula in the scapus supras subscapularis subscapular fossa will see subscapularis muscle and this is the td minor which you are not seeing in the previous view so we have subscapular supraspinatus intraspinatus and series minor form the rotator cuff muscles so the next one is we should always see the rotator interval what is rotator interval it is the space between the supra subscapularis muscle interiorly and the interior aspect of supraspinatus muscle so the white arrow it is marked there in the second view this is the space for rotator cuff interval okay so which structure is present in this rotator cuff interval is that has biceps long head of biceps tendon and that is being supported by subscapularis muscle so whenever there is tear or injury to the subscapularis muscle there will be dislocation of biceps tendon from the bicipital groove from this uh rotator cuff interval out of that bicipital group now we'll see some slides for axial view section by section from the superior aspect from the left corner side we'll see the uh from the interior aspect we are seeing the clavicle then lateral aspect of the clavicle is articulating with the anterior anterior most aspect of the acromion process forming acromioclavicular joint so section by section which we should see everything for what we have imaged for so initially we have seen in the first view we we have seen acromioclavicular joint and anterior and posterior fibers of deltoid and anterior to the deltoid we push a fiber of deltoid we have supraspinatus muscle we will go to next section we can see the bulk of supraspinatus muscle in the third view the arrow marked this coracoid process in the next section we can see the structure which is marked there is a rotary curve interval which is which i have already told that is between subscapularis muscle which will come anterior to the like on the inferior side of the correct process from the scapular fossa to the lesser tuberosity so in between these two subs this one supraspinatus and subscapularis muscle there will be rotator interval this is supraspinatus and this is a subscapularis muscle it will it will form uh there will be rotator cuff interval and the on the last size last slide we can see uh the supra subscapularis muscle and later in the posterior aspect of scapula you can see infraspitous muscle and posterior most we have posterior fibers fibers of deltoid muscle now what we'll see if i'll tell you this is the normal anatomy uh we we have to see the normal thing first before going to the abnormal that my seniors and my consultant told me so normally the muscle will appear to low signal intensity on mri both on t1 and t2 if you are seeing hyper signal in increased signals in signal intensity or high signal intensity on t1 and t2 okay or pdfs image we will we will see there is tendinitis in that tendrilopathy of that particular uh rotary cuff tendon or anything wherever it is so in tendinopathy there will be increased signal intensity on t1 and t2 both so in this image we can see there is increased signal intensity in the supraspinatus tendon near to the near to its standard attachment so that suggests supraspinatus supraspinatus tendinopathy next i have already told i have already showed on x-ray also there is hyper like calcification on the supraspinatus tendon on mri calcification will appear totally black near to black or low signal intensity on t1 and t2 both so uh on left upper image you can see there is hypoecho high point density seen near to the supraspinatus tendon insertion and for that if ultrasound will be done we will see multiple pacific foci within the tendon attachment so that is calcific tendinitis now we should always see uh supra like atrophy of the rotator cuff muscles like if i say per se it's not always the tear it can be nerve injury also which uh like whatever nerve is supply the muscle is supplied by the now if now get injured this muscle will get atrophied so we should always see the brachial plexus also the nerves also uh to scan whether the whether it is due to some tendency here or because of the nav injury so uh if i tell this normally roughly then like yeah now now supply of muscles so subscapularis muscle is supplied by super uh superior inferior subscapularis now the supraspinatus and infraspinatus muscle are supplied by supra supraspinatus now suprascapular now then if you will see in this one uh left upper corner we can see the almost whole of the supraspinatus fossa is filled by supraspinatus muscle in the lower right image you can see there is increase the content or muscle bulk of the supraspinatus muscles muscle has decreased so that is atrophy of the supraspinatus muscle similarly you can see in infraspinatus muscles muscle also because the suprascapular nerve traverses from the brachial plexus from the brachial plexus to spinoglenoid notch before going to spinoglenoid notch which is present on the lateral aspect of spine of scapula and the medial aspect of glenoid glenoid cavity or glenoid surface that is super uh spinal glenoid notch so from that surface from that area suprascapular nerve will go and give branch to supraspinatus muscle first then to infraspinatus muscle if there is injury uh of the suprascapular nerve above that there will be a trophy of both the muscles supraspinatus and as well as infraspinatus but if there is injury of this nerve beyond the spinal glenoid notch there will be only involvement of infra infraspinatus muscle so we should always we should also remember the nerve supply and the basic uh like brachial plexus anatomy of shoulder joint also like near to the shoulder joint now we have seen the tendinopathy this is the image showing full thickness tear of supraspinatus muscle and it's showing bit retraction also so in this one we'll see there is no evidence of any tendon present from the articular surface till the bursal surface and there is only increased signal intensity in that area so it suggests complete or full thickness rotator cuff tendon here or supraspine steer so this i have included because this is the common finding we see in day to day life patient come to us or from the ortho petition side the patient is not able to move his shoulder joint properly there is some restriction of the shoulder joint movements so what we will see we will see there is increased signal intensity as well as enhancement basically if it is there increase signal intensity as well as enhancement in rotator cuff interval specifically then we make the diagnosis towards the adhesive capsulitis or frozen shoulder so this this finding we usually see uh in this uh as adhesive casper like this also there will be an auxiliary resist thickening and edema will be there sorry auxiliary such thickening and enema will be there in that area you can see there is increased signal intensity in auxiliary recess area as well as edema one minute now this is the area of rotator cuff interval which i was talking about so if there is increased thickening increase thickening as well as enhancement in that rotator cuff interval that is bit it is more towards the diagnosis for adhesive capsulitis now three slide i have put just to show everyone which i might have forgotten to tell you uh within the session that in coronal view we should always see bones and bone marrow both and in coronal view we'll see fluid in spectrometer sub deltoid bursa or joint diffusion rotator cuff rotator cuff mainly you'll see supra and infraspinatus muscle on glen glenohumeral articular cartilage and superior labrum biceps tendon on subjectal view as we have seen on cut section the ph shape structure of glenoid anteriorly we have subscapularis posteriorly we have supra infra and theories minor then we should always see intra-articular area interarticular region of biceps tendon to see whether there is any tear or not no like it has been said that a minimal fluid in the bicipital groove around the recipiental tendon is can be normal also so we should always have in mind that if there is minimal fluid around the bicep within the visceral group if no symptoms are there keep it as normal and always see any atrophy of the muscle then on axial view we will see properly subscapularis muscle long head of biceps tendon traversing from the medial aspect to the lateral aspect into the bicipital group anterior posterior labrum as well as glenohumeral ligaments and glenohumeral cartilage as well as capsule and specifically i know rotator cuff is a important topic but we have lot more in the shoulder joint which we can't cover in the in this single session we have impingements impingement impingement syndromes atrophy like parsonage turner syndrome and tears liberal tears so that is that is also to be mentioned clearly whether there is any tear or not if there is subtle partial thickness tear so we should all or liberal tier mr orthography is best and mr orthography should be done in ever position that is abduction arm should be abducted and in external rotation that is abduction and external rotation always do mr arthrography in ever position because what's the reason uh reason is you will increase the tension if there is any tear the like super solution we call it super solution for mr orthography that the solution will go and penetrate the structure it will get disclosed within the ten tendon tears or liberal tears we can clearly see them uh on particular sections in ever position so for liberal tears or partial thickness subtle partial thickness tears we should go for mr arthrography and the content in the report should be like it's a lengthy report so at least we should have what type of tier it is it is whether it is partial or complete and what is the size of the ta what's the distance of the tier from the rotator interval and whether there is retraction of the fibers that will be seen in cases of full thickness completely and also see if it is a chronic chronic case you should always see what is the like whether there is any muscle atrophy there or not so what's the sequence whether when there is a tear the muscle is torn when there is a tear this tear will lead to degeneration degeneration like there will be fatty accumulation within the muscle that muscle will be continuously replaced by the fatty fatty streaks and for that we have classification also we'll discuss uh right now uh then the muscle will be converted into fat guttalia's classification is there the total five uh types are there based on the percentage of fat within the muscle atrophied muscle we have they have divided so uh muscle atrophy is then how much a trophy is there we should we should mention and session is like over we will have i i i want to thank my all of my seniors like my hod server rajesh malik my guide dr radha s gupta everyone knows and all my juniors dr ghosh dr ankit shah and radiology assistant and radiology nation i am very thankful to all of you and whatever whatever i am today i'm all because of you thank you so much and now we will have uh can we have the questions please uh sure just just normal questions we'll have uh okay i'll run the first poll so you can scroll down actually to see all the options and then click and submit this is rotator interval is bit is in between which two muscles as we have discussed nice that is between subscapularis and supraspinatus muscle great awesome next one as we have discussed what is the content of rotator interval nice that is biceps and long header biceps brachii is the content of rotator cuff and interval which rotator cuff muscle doesn't blend with capsule of shoulder joint this is the question we have infraspinatus supraspinatus subscapularis series major [Music] metabolism uh i want to mention all the rotator cuff muscles blend with the capsule of the shoulder joint so you will have uh like supraspinatus and transplanters tds miner and subscapularis series major is not the part of rotator cuff muscles which is not the abductor of shoulder joint later we'll discuss the degrees of abduction of shoulder joint according to the tendon perfect why it is not abductive because subscapularis muscle uh origin is subscapularis fossa fossa to the lesser tuberosity lesser tuberosity it cause it causes medial rotation internal rotation of shoulder joint however if we'll say what are the abductors of shoulder joint we have initially 0 to 15 degree is done by supraspinatus muscle uh then 15 to 90 degrees then by deltoid muscle and later on till 180 degree it is done by trapezius muscle bare humeral signs seen in where humeral head sign seen nice uh bare humeral sign what what bare numeral sign is uh as we have seen the supraspinatus tendon is completely attached to the head of the humerus uh through the footprint if there is no there is no supraspinatus tendon that is complete thickness here with retraction there is no nothing on the head of the humerus other than the capsule so that is called bare humeral head sign we mentioned critical zone tier in case of rotator cuff tendons so what is the critical zone critical zone for rotator cuff that question we usually like i have searched that's why i put so everyone can know if nobody and if you don't know just a guess actually it's good 30 percent voted for 8 to 20 mm this is the correct answer 8 to 20 mm is the critical critical tier zone critical zone for a tier of rotator cuff tendons 8 to 20 mm petty classification petty classification is rotator cuff tendon is used for what that is important from orthopedician point of view nice it is for full thickness here supraspinatus tendon in in this one what's there if this is the canon attachment and this is the head of humerus if it is near there are three grades three stages for this petas classification stage one is just retracted tendon is near to the insertion site that is stage one if it is above the head of humerus it is stage two and if it is going beyond the glenoid cavity of scapula that is stage three okay there are three stages for pate near to the site of an insertion stage one over the head of humerus stage two and third one is uh beyond the scap glenoid fossa one more classification battalions as i have already told for degeneration and atrophy and fatty infiltration within the muscle there are a total five stages what is that grade zero is normal if nothing is there if a trophy is not there then grade one is mild fatty streaks of uh mild fat districts are there then grade two three and four is just remember fifty percent if it is less than fifty percent rate two more than uh fifty percent grade three and if it is more than uh fifty percent that is entire muscle bulk is replaced by the fat that is fatty infiltration within the muscle totally fat infiltration that is great for this is for everyone anyone can cop opt anything it's like pgi type question [Music] thank you so much this is for me actually i should have better knowledge okay thank you so much thank you so much for listening the session i'm honored to be there to be here we are not that you actually came here and the session was really informative for everyone i really got a lot of information on radiographs and the whole shoulder joint which was frankly a little confusing before but you made it really simple so thank you um thank you so much i think we have a few questions let me just check and so we have one question uh where is biceps anchor and what forms it biceps anchor the tendon of biceps long hair biceps tendon is uh biceps anchor near to the glenoid uh supraglenoid uh region soup we usually define the term this term uh when we say liberal tears uh orthopedician and most of the radiologists might knowing this because we differentiate slapped here uh from the sub laboratory recesses and the foramen sub label foramen that term is used there because slab tear will extend into the bicipital anchor it will involve the bicipital tendon bicep death biceps anchor while the sublabeler sub liberal foramen and recesses won't include i think uh the doubt is clear yes i yeah i think that yes it is uh i think uh those were it and um yeah if in the audience if anybody has any other questions you all can uh send us an email and at support.netflix dot app and we'll get back to you we'll check with dr varun and get back to you if y'all have any uh issues and for the audience if y'all have any suggestions for any speakers or any topics that you would like to hear or please do write to us same address and we'll try to hold those whole sessions on those topics specifically and thank you dr varun so much for the session we hope to have you again on our platform and thank you all for joining on a sunday morning and enjoy your remaining weekend

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SPEAKERS

dr. Varun Kumar

Dr. Varun Kumar

MBBS, Maulana Azad Medical College | MD, Radiology, AIIMS, Bhopal | Radiologist, Dr. Baba Saheb Ambedkar Hospital, New Delhi NOW Senior resident at Maulana Azad Medical College, New Delhi

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dr. Varun Kumar

Dr. Varun Kumar

MBBS, Maulana Azad Medical College | MD, Radi...

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