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PubMed2001

[Overuse injury syndromes in the shoulder area].

The shoulder is the most movable and the most unstable joint in a human body. The glenohumeral joint is particularly vulnerable because overhead activities put tremendous stress on its static stabilizers (ligamentous labral complex) and the dynamic stabilizers (rotator cuff muscles). Overhead activities may stretch or injure the static stabilizers. Minor aberrations in mechanisms controlling stability have a significant and cumulative effect on the shoulder biomechanics, and increase the risk of injury. Impingement syndrome and glenohumeral instability are predominant injuries affecting the shoulder.

Biomechanical Phenomena↗
PubMed1995

Three-dimensional MRI of the glenoid labrum.

The objective of this study was to assess the accuracy of three-dimensional (3D) magnetic resonance imaging (MRI) reformation in the evaluation of tears of the glenoid labrum complex (GLC). Fifty-five shoulders were evaluated by MRI using standard spin-echo sequences. Gradient-refocused-echo axial projections were used to assess the GLC on the two-dimensional (2D) studies. Three-dimensional Fourier transform multiplanar gradient-recalled imaging with a resolution of 0.7 mm was also performed in all patients. Independent analyses of the anterior and posterior labra were performed in a blinded manner for both the 2D and 3D studies by three experienced musculoskeletal radiologists. Observations of the imaging studies were compared with the videoarthroscopic findings. The appearance of the GLC was rated on a scale of 0 to 4 (0-2 = normal, 3, 4 = abnormal or torn). The diagnostic confidence was averaged from the three reader's scores. Anterior labral tears were effectively detected with sensitivities of 89% and 96% and specificities of 96% and 100% (P < 0.0001) for the 2D and 3D studies, respectively. For posterior labral tears, the sensitivity and specificity of the 2D method were 47% and 98%, respectively. The sensitivity and specificity of the 3D volume sequence were 53% and 98%, respectively. The lower sensitivity of both imaging methods for detecting posterior labral tears may be influenced by the smaller number (n = 5) of arthroscopically confirmed cases in our study and reflects the difficulty of visualizing the posteroinferior borders of the GLC with present MRI techniques.

Adult↗
PubMed1999

Fat-suppressed fast spin-echo mid-TE (TE[effective]=34) MR images: comparison with fast spin-echo T2-weighted images for the diagnosis of tears and anatomic variants of the glenoid labrum.

OBJECTIVE: To compare the sensitivity, specificity, and accuracy of fat-suppressed fast spin-echo (FSE) mid-TE (TE[effective]=34) images with fat-suppressed FSE T2-weighted images for the diagnosis of labral abnormalities. DESIGN AND PATIENTS: The study included 27 consecutive patients who had axial fat-suppressed FSE T2-weighted and fat-suppressed FSE mid-TE MR images, and had labral abnormalities diagnosed at arthroscopy. The acquisition time was about 5 min for each sequence, but the mid-TE sequence allowed a higher spatial resolution than the T2-weighted images (256x256 versus 256x192). Twenty-eight age-matched patients with arthroscopically normal labra were included as a control group. The labrum was graded on the MR images as normal or abnormal separately by two musculoskeletal radiologists who were masked to the history and arthroscopic results. The surgical findings were used as the gold standard for calculating the sensitivity, specificity, and accuracy for interpreting the correct location of a labral abnormality. The sensitivity, specificity, and accuracy for the two sequences were compared with a McNemar test, and significance defined as P<0.05. RESULTS: For observer 1, the sensitivity for labral abnormalities was 0.59 on the T2-weighted images, and 0.78 on the mid-TE images (P=0.12). The specificity was 0.54 for the T2-weighted, and 0.64 for the mid-TE images (P=0.51). The accuracy was 0.56 for the T2-weighted, and 0.71 for the mid- TE images (P=0.08). For observer 2, the sensitivity/specificity/accuracy was 0.67/0.93/0.80 for the T2-weighted, and 0.70/0.86/0.78 for the mid-TE images (all P>0.5). CONCLUSION: In this small study there is no statistically significant difference for demonstrating labral abnormalities between FSE T2-weighted images, and higher-resolution fat-suppressed FSE mid-TE (TE[effective]=34) images obtained with a similar acquisition time. Although there was a general trend toward higher sensitivity and accuracy with the mid-TE sequence, particularly for one of the two observers, a larger study is needed to determine whether this is the preferred single axial pulse sequence for conventional MR imaging of the labrum.

Adolescent↗
PubMed2006

Quantifying the extent of a type II SLAP lesion required to cause peel-back of the glenoid labrum--a cadaveric study.

PURPOSE: To quantify the extent of labral disruption required to cause it to peel back when the peel-back test is performed. METHODS: Ten cadaveric shoulders were prepared by removal of the deltoid and rotator cuff muscles. The glenohumeral joint was concentrically reduced and brought into 90 degrees abduction and maximal external rotation. The peel-back of the labrum was graded 0, 1, or 2. The labrum was sequentially detached from the glenoid in the following order: biceps anchor only, 1 o'clock, 2 o'clock, 11 o'clock, and 3 o'clock positions. After each labral cut, the peel-back test was performed. Labral repair was performed with a single suture anchor placed at the 12:30 o'clock position; labral peel-back was reassessed. RESULTS: A progressive increase was noted in peel-back grade with sequential cutting of the labrum posteriorly. However, disruption of the anchor alone did not lead to a positive peel-back sign. Disruption to the 2 o'clock position resulted in a positive peel-back sign overall in 9 of 10 shoulders (5 were grade 1, and 4 were grade 2). No increase was seen in peel-back grade with anterior extension of the labral detachment. Labral repair with a single anchor placed at the 12:30 o'clock position eliminated labral peel-back in 100% of shoulders. CONCLUSIONS: Detachment of the biceps anchor alone does not cause peel-back. The labrum must be disrupted to at least the 2 o'clock position before overt (grade 2) peel-back is observed. A single suture anchor placed at 12:30 o'clock eliminated peel-back of the labrum. CLINICAL RELEVANCE: Validation of the peel-back test as an important diagnostic tool during shoulder arthroscopy.

Adult↗
PubMed2006

Clinical outcome of anterior shoulder instability with capsular midsubstance tear: a comparison of isolated midsubstance tear and midsubstance tear with Bankart lesion.

To analyze the clinical outcomes of patients with a midsubstance capsular tear for anterior shoulder instability, 21 shoulders with a midsubstance tear were reviewed. There were 7 isolated midsubstance tears (group I) and 14 combined midsubstance tears with Bankart lesions (group II). The Rowe score averaged 92.3 points with 6 excellent and 1 good one in group I. Group II scored 86.3 points with 8 excellent, 3 good, 2 fair, and 1 poor (P = .184). The Rowe score averaged 89.8 points for the cases with an arthroscopic procedure and 86.9 points with an open repair (P = .542). At the last follow-up, forward elevation increased by 6 degrees in group I and 8 degrees in group II (P = .432). External rotation decreased by 8 degrees and 16 degrees , respectively (P = .150). The clinical outcomes of anterior instability with a midsubstance tear were good in both groups. The loss of external rotation was greater in the cases with combined midsubstance tears and Bankart lesions than in those with an isolated midsubstance tear.

Adolescent↗
PubMed1994

MRI of the shoulder.

MRI of the shoulder is widely considered the imaging modality of choice in the evaluation of shoulder pain and the clinical impingement syndrome. This is because of its direct evaluation of all of the soft tissue structures of the subacromial space, as well as its ability to depict the relationship of the overlying osseous and soft tissue structures of the coracoacromial arch. It also provides information regarding the capsulolabral anatomy and, with the addition of MR arthrography, is becoming recognized as the imaging modality of choice for instability workup. MRI evaluation, when combined with the always important clinical history, physical examination, and radiographs, provides the referring clinician and orthopedic surgeon with the most anatomic and pathological information possible. This, in turn, allows the most informed decision making possible regarding conservative management or surgical treatment.

Humans↗
PubMed2005

Conventional radiography of the shoulder.

Conventional radiography is a useful tool in the evaluation of shoulder pain whether in the setting of acute trauma or chronic pain and in most clinical situations should be the first imaging modality performed. Knowledge of the various projections and radiographic findings described above will ensure an optimal evaluation of the shoulder regardless of the suspected etiology of the shoulder pain.

Humans↗
PubMed2003

[Indirect MR-arthrography of the shoulder-value in the detection of SLAP-lesions].

PURPOSE: A prospective study to assess the value of indirect magnetic resonance-arthrography (MR-Arthro) in the detection of lesions of the superior labrum (SLAP-lesions). MATERIALS AND METHODS: Unenhanced magnetic resonance imaging (MRI) and indirect MR-Arthro of the shoulder were performed in 35 patients (9 females and 26 males) with a history of acute or chronic shoulder disorder. The images of unenhanced MRI and indirect MR-Arthro were analyzed independently from each other for the occurrence of SLAP-lesions and the findings correlated with the arthroscopic results. For arthroscopy, MRI and MR-Arthro, the SLAP-lesions were categorized based on the classification system of Snyder. RESULTS: SLAP-lesions were diagnosed by arthroscopy in 22 of 35 patients (63 %). 9 of the 22 lesions (41 %) were classified as type 1, 9 (41 %) as type 2, three (13.5 %) as type 3 and one (4.5 %) as type 4. Using unenhanced MRI sensitivity, specificity and accuracy in the detection of SLAP-lesions were calculated to be 73 %, 85 % and 77 %. Indirect MR-Arthro showed a sensitivity of 91 %, a specificity of 85 % and an accuracy of 89 %. Unenhanced MRI revealed correlation to the arthroscopic classification in 9 of 22 cases (41 %) and indirect MR-Arthro in 18 of 22 cases (82 %). CONCLUSION: Indirect MR-Arthro is a non-invasive method which offers excellent sensitivity in the diagnosis of SLAP-lesions. It provides important preoperative informations with regard to the exact location and extent of a tear.

Adult↗
PubMed1988

Peribursal fat plane of the shoulder: anatomic study and clinical experience.

A comprehensive anatomic and radiographic analysis of the peribursal fat plane in 12 cadavers confirmed that the fat plane seen on radiographs represents extrasynovial fat lining the subacromial bursa and documented the anatomic relations of the bursa. A three-part retrospective clinical evaluation of rotator cuff tears, calcific tendinitis, and rheumatoid arthritis was performed. Two osteoradiologists blindly graded the appearance of the peribursal fat plane with the shoulder in external versus internal rotation in 21 patients with arthrographically intact rotator cuffs and 21 patients with disrupted rotator cuffs. The peribursal fat plane was seen better with disrupted rotator cuffs. The peribursal fat plane was seen better with the shoulder in internal rotation and was seen in 60% of control subjects but only 21% of patients with rotator cuff tears. Partial or complete obliteration of this fat plane is a sensitive (79%) but less specific (60%) indicator of rotator cuff tears. Obliteration of the peribursal fat plane by inflammatory processes in adjacent tissues, including calcific tendinitis and rheumatoid arthritis, occurred with a high frequency.

Adipose Tissue↗
PubMed1989

Rotator cuff tears: diagnostic performance of MR imaging.

To determine the diagnostic performance of magnetic resonance (MR) imaging in the evaluation of suspected rotator cuff tears, eight asymptomatic volunteers and 32 patients with rotator cuff tendonopathy who underwent surgery were examined with MR imaging. Twenty-four of these patients also underwent contrast arthrography. The ability of MR imaging to depict the size of cuff tears and the quality of torn tendon edges was also evaluated. The MR imaging and arthrographic studies were reviewed without knowledge of surgical results or of the other studies. A scoring system was developed and a score assigned to each patient's MR study. The sensitivity of MR imaging for all tears (partial and full thickness) was 0.91, and the specificity was 0.88; whereas the sensitivity and specificity of arthrography were each 0.71. The scoring system improved the sensitivity to 1.0 and the specificity to 0.92. Linear regression analysis showed excellent correlation between preoperative assessment of the size of rotator cuff tears and measurement at surgery (r = .95).

Humans↗
PubMed1992

Normal and abnormal glenoid labrum: assessment with multiplanar gradient-echo MR imaging.

A retrospective study of magnetic resonance (MR) imaging of the glenoid labrum performed with multiplanar gradient-echo (MPGR) sequences was done to ascertain the different appearances of the normal labrum and the findings in patients with tears. MPGR images were obtained with a 1.5-T magnet in 37 shoulders of 16 healthy subjects and 19 patients with subsequent surgical evaluation. Increased intralabral signal intensity was seen in 12 of 26 normal shoulders (46%), and atypical morphology was seen in six shoulders (23%). Atypical morphology was present in eight of nine patients with labral tears. Deformity (n = 2 [22%]) and clefts (n = 2 [22%]) were seen in patients with tears. Deformity (n = 3 [12%]) and clefts (n = 1 [4%]) were occasionally seen in healthy subjects. Absence of the labrum and separation of the labrum from the glenoid cavity was present only in patients with tears; therefore, the labrum should be presumed torn in the presence of these findings. Increased intralabral signal intensity on MPGR images did not help predict labral integrity; morphologic findings were more predictive of labral tear.

Adolescent↗
PubMed1995

Glenohumeral ligaments and shoulder capsular mechanism: evaluation with MR arthrography.

PURPOSE: To evaluate the efficacy of magnetic resonance (MR) arthrography in identification of the glenohumeral ligaments (GHLs) and to determine the location of abnormalities of the GHL, joint capsule, and labrum. MATERIALS AND METHODS: MR arthrograms were evaluated retrospectively in 46 patients with a history of shoulder instability, impingement syndrome, or pain of unknown cause. Imaging findings were correlated with surgical observations. RESULTS: The superior, middle, and inferior GHLs were identified on MR arthrograms in 39 (85%), 39 (85%), and 42 (91%) of the 46 patients, respectively. In diagnosis of tears of the superior, middle, and inferior GHLs, MR arthrography had a sensitivity of 100%, 89%, and 88% and a specificity of 94%, 88%, and 100%, respectively. CONCLUSION: Findings at MR arthrography can help accurate identification and demonstration of the integrity of the GHL and labrum and can help in staging of abnormalities. The large number of abnormalities depicted in the middle and inferior GHLs suggests that both might be important in the maintenance of glenohumeral joint congruity.

Adult↗
PubMed1995

MR diagnosis of labral tears of the shoulder: value of T2*-weighted gradient-recalled echo images made in external rotation.

OBJECTIVE: Because several studies have shown that conventional MR imaging can fail to diagnose a significant percentage of labral tears, some authors have proposed obtaining T2*-weighted gradient-recalled echo images with the humerus in external rotation. The purpose of our study was to determine whether the diagnostic accuracy of detecting anteroinferior labral tears by MR imaging would be improved by adding a T2*-weighted gradient-recalled echo sequence with the humerus in external rotation. MATERIALS AND METHODS: The study included 24 patients for whom axial MR images of the shoulder were obtained with the humerus in both the neutral position and external rotation. Two observers interpreted the images made in the neutral position and then noted any change in their interpretations after viewing findings on the external-rotation images. MR results were correlated with surgical findings. At surgery, 14 anteroinferior labra were found to be torn and 10 were found to be intact. RESULTS: Both observers identified one patient for whom a surgically proved labral tear was seen only on the external-rotation images. The sensitivity increased from 0.43 to 0.50 (p = .35) for observer 1 and from 0.36 to 0.43 (p = .35) for observer 2. The specificity of 0.90 for both observers remained unchanged. The accuracy improved from 0.62 to 0.67 for observer 1 and from 0.55 to 0.62 for observer 2. CONCLUSION: The addition of external-rotation T2*-weighted gradient-recalled echo images to the MR examination for tears of the anteroinferior labrum leads to a small but statistically insignificant increase in diagnostic sensitivity. We conclude that the small increase in sensitivity does not justify the routine use of this sequence.

Adolescent↗
PubMed1996

The Buford complex--a variation of normal shoulder anatomy: MR arthrographic imaging features.

OBJECTIVE: The purpose of this study was to show the MR arthrographic imaging features of a normal anatomic variation of the shoulder: the absence of the anterior superior labrum and the presence of a "cordlike" middle glenohumeral ligament,which together are known as the Buford complex. MATERIALS AND METHODS: We retrospectively analyzed the MR arthrographic examinations of 10 patients with arthroscopically proven Buford complexes. RESULTS: MR arthrographic examinations showed an absent anterior superior labrum and an associated cordlike middle glenohumeral ligament in all patients. No contiguous tear of the superior labrum or anterior inferior labrum was evident. Originally, this variation was mistakenly diagnosed as a labral avulsion in two of the 10 patients. Also, a differential diagnosis of a superior labral tear was mistakenly offered for four patients. CONCLUSION: An absent anterior superior labrum and an associated cordlike middle glenohumeral ligament represent the normal variation that is known as the Buford complex rather than an avulsed labrum. This normal variation may be mistaken for a detached labrum.

Adolescent↗
PubMed1997

Using abduction and external rotation of the shoulder to increase the sensitivity of MR arthrography in revealing tears of the anterior glenoid labrum.

OBJECTIVE: The purpose of this study was to compare oblique axial MR arthrograms obtained with the patient's shoulder in abduction and external rotation (ABER) position with conventional axial MR arthrograms obtained with the patient's arm in neutral position and the shoulder not rotated in revealing tears of the anterior glenoid labrum (AGL). SUBJECTS AND METHODS: MR arthrography of the shoulder that included an additional oblique axial imaging sequence with the patient in the ABER position was performed in 256 patients. Assessment of AGL integrity with patients in both conventional axial and ABER positions was made before surgery. These assessments were compared with the surgical findings. RESULTS: Of the 92 patients who underwent surgery, AGL tears were found in 27. Conventional axial MR arthrograms revealed 13 tears (sensitivity, 48%; specificity, 91%). A separate review of MR arthrograms obtained with patients in the ABER position revealed 24 tears (sensitivity, 89%; specificity, 95%). Reviewed together, axial MR arthrograms and MR arthrograms obtained with patients in the ABER position revealed 26 tears (sensitivity, 96%; specificity, 97%). CONCLUSION: Oblique axial MR arthrograms obtained with the patient's shoulder in the ABER position were significantly more sensitive in revealing AGL tears (p = .005) than were conventional axial MR arthrograms obtained with the patient's aim in a neutral position and the shoulder not rotated.

Adolescent↗