|Year : 2017 | Volume
| Issue : 1 | Page : 7-10
Diagnostic role of magnetic resonance imaging in rotator cuff pathologies
Gaurav Kumar, Suresh V Phatak, Bhushan Lakhkar, Sanjay Kumar Yadaw
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
|Date of Web Publication||25-Jul-2017|
Suresh V Phatak
Teachears Flat, AVBRH Complex, JNMC Campus, Sawangi (Meghe), Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims and objectives: 1. To study the rotator cuff pathologies and association of rotator cuff pathologies with acromion morphology and biceps (long head) pathologies. Material and Methods: 100 patients clinically suspected of rotator cuff pathologies were evaluated using 1.5 tesla MRI for the rotator cuff tendon tears/tendinosis and associated acromion morphology and biceps tendon(long head) pathologies. Results : The average age of the patients was 41.73±16.55 years with male dominance (84%).Out the 100 patients, supraspinatus was the most common pathological tendon with 81% cases showing abnormalities. The rotator cuff tears were more common in the later age groups and tendinosis more common in the early age groups. Partial tears of rotator cuff were more common than complete tears.58% cases showed partial tears in supraspinatus as compared to 14% cases of complete tears. Articular surface tears were most common partial tears seen in 46.5% cases.Variation in the acromion morphology Biceps(long head) pathologies showed positive correlation with the rotator cuff pathologies Conclusion: MRI is a valuable modality to diagnose and characterise the rotator cuff and associated pathologies.
Keywords: Acromion, biceps, rotator cuff, supraspinatus
|How to cite this article:|
Kumar G, Phatak SV, Lakhkar B, Yadaw SK. Diagnostic role of magnetic resonance imaging in rotator cuff pathologies. J Datta Meghe Inst Med Sci Univ 2017;12:7-10
|How to cite this URL:|
Kumar G, Phatak SV, Lakhkar B, Yadaw SK. Diagnostic role of magnetic resonance imaging in rotator cuff pathologies. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Jun 16];12:7-10. Available from: http://www.journaldmims.com/text.asp?2017/12/1/7/211572
| Introduction|| |
The shoulder joint is one of the most complicated joints in the body. The glenohumeral joint is a ball-and-socket type of synovial joint where humeral head articulates with the glenoid cavity of the scapula. The articular surface of the humeral head is larger as compared to the glenoid fossa which is a primary cause of instability in this joint. The joint stability is provided by two set of the stabilizers – passive and active. Rotator cuff is an important active stabilizer of the glenohumeral joint. Rotator cuff consists of four muscles and their tendons, namely, supraspinatus, infraspinatus, subscapularis, and teres minor. It is predisposed to a variety of the external and internal stress factors. The external factors include trauma, and internal factors on the other hand include primary impingement due to overlying acromion and acromioclavicular joint hypertrophy and secondary impingement due to glenohumeral joint instability. There is another intrinsic theory of the rotator cuff pathology which explains intrinsic degeneration as the primary cause of the rotator cuff tears. Rotator cuff pathologies can be evaluated with the secondary changes in the biceps tendon (long head).
Magnetic resonance imaging (MRI) plays an important role in the evaluation of the rotator cuff pathologies. MRI provides good spatial resolution together with the multiplanar imaging which allows evaluation of the fine details associated with rotator cuff. Its accuracy is comparable to the ultrasound in diagnosis of the rotator cuff lesions; however, it is not operator dependent like sonography. Its superior ability to demonstrate soft tissue structures together with its noninvasiveness nature has made it the imaging modality of choice to evaluate the rotator cuff.
| Materials and Methods|| |
The study was approved by the Institutional Ethics Committee of the DMIMS (DU). All patients were included in the study after written consent was obtained. The patients were referred from the Orthopedics Department of Jawaharlal Nehru Medical College with clinical suspicion for the rotator cuff pathologies. All the patients were evaluated for the rotator cuff lesions and associated acromion morphology and biceps tendon status. The study included 100 patients with exclusion of the cases of tumors and infection and patients with contraindication to the MRI.
MRI was performed using a 1.5-tesla Brivo MR 355 machine using flexible surface coil. The patient was made to lie in a supine position with the head end toward the scanner bore. The patient's arm was placed to the side of the patient and in external rotation. The MRI scanning protocol included imaging in the axial, coronal oblique, and sagittal oblique as follows: oblique coronal T1-weighted image (time to repeat (TR): 400–600; time to echo (TE):12 ms; field of view (FOV): 16 cm × 16 cm; matrix: 320 × 256; slice thickness: 5 mm; interslice gap: 1 mm); oblique coronal T2-weigted image (T2WI) with fat suppression/STIR (TR: 2700–3500; TE: 102 ms; FOV: 16 cm × 16 cm; matrix: 320 × 256; slice thickness: 5 mm; interslice gap: 1 mm); coronal proton density (PD) fat-saturated (fatsat) images (TR: 2880; TE: 40 ms; FOV: 16 × 16 cm; matrix: 320 × 256: slice thickness: 5 mm; interslice gap: 1 mm); sagittal PD fatsat (TR: 2880; TE: 40 ms; FOV: 16 cm × 16 cm; matrix: 320 × 256; slice thickness: 5 mm; interslice gap: 1 mm); axial PD fatsat/STIR (TR: 2880; TE: 40 ms; FOV: 16 cm × 16 cm; matrix: 320 × 256; slice thickness: 5 mm; interslice gap: 1 mm).
Image interpretation was done for the rotator cuff tears, tendinosis, acromion morphology, and biceps tendon pathologies. Partial tears were seen as the focal area of increased signal intensity on PD fatsat and T2 fatsat images with partial tendon disruption. Complete tears are seen as full-thickness tendon breach with increased signal intensity on PD fatsat and T2WI. Tendinosis is seen as focal increased signal intensity on PD fatsat images without tendon breach. Acromion can be divided into four types depending on the undersurface morphology – Type I with flat, Type II with concave, Type III with hooked, and Type IV with convex undersurface. Biceps tendon was evaluated for tenosynovitis, tendinitis, and tendon tears.
| Results and Observations|| |
The study was carried out in a sample size of 100 patients comprising 84 males and 16 females. The most common tendon involved was supraspinatus showing abnormalities in 81% cases [Graph 1]. The teres minor tendon was normal in all cases.
The age distribution of the rotator cuff pathologies was further assessed. The tears of the rotator cuff were more common in the later age groups; however, the tendinosis was more common in the younger patients. For supraspinatus tendon, 69.5% of the cases of the tendinosis occurred before the age of 45 years and 67% of the tears (partial and complete) occurred after the age of 45 years. A similar trend was seen for other rotator cuff tendons. In our study, partial tears of rotator cuff were more common than the complete tears. Partial [Figure 1] and complete tears were seen in 58% and 14% cases, respectively, for supraspinatus. A similar trend was seen in the other tendons of the rotator cuff. Among the partial tears of the supraspinatus, articular surface tears were most common and seen in 46.5% cases.
|Figure 1: (a and b) Magnetic Resonance Imaging Coronal proton density fat saturated (a) showing bursal surface partial supraspinatus tear(single arrow in A) with type III acromion with acromio-clavicular joint hypertrophy (double arrow in B)|
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Further, acromion morphology was assessed in relation to the rotator cuff tears. Type II acromion was most commonly seen in the study, occurring in 49% of cases. The variation in the acromion morphology showed a positive correlation with the rotator cuff pathologies (P < 0.05) [Graph 2]. Biceps (long head) tendon showed pathologies in 60% of the evaluated cases. Biceps pathologies showed positive correlation with the rotator cuff injuries (P < 0.05) [Table 1]and [Figure 2].
|Table 1: Rotator cuff pathologies and biceps tendon (long head) pathologies correlation|
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|Figure 2: (a and b) Magnetic resonance imaging coronal (a) and axial (b) proton density fat saturated images showing complete thickness supraspinatus tear with bicipital tenosynovitis|
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| Discussion|| |
MRI is a sensitive modality for the evaluation of the rotator cuff pathologies and has important implications in the further management of the rotator cuff pathologies. With the advent of the surface coils, the MRI has been widely used for the evaluation of the rotator cuff pathologies such as tears and tendinosis.
Our study included 100 patients clinically suspected of rotator cuff pathologies. The supraspinatus tendon showed abnormalities in the maximum number of cases (81%), followed by subscapularis tendon and infraspinatus. We did not receive any tear/tendinosis of teres minor tendon. Garavaglia et al. in a retrospective study of 348 patients comparing MRI and arthroscopy findings found supraspinatus tears in the 311 (89%) patients followed by subscapularis (37%) and infraspinatus (14%) tendons. Jerosch et al. in cadaveric study in 122 patients got isolated supraspinatus tears in 78% cases with none of the rotator cuff tears occurring without supraspinatus involvement.
Rotator cuff pathologies were further classified into tendinosis, partial tear, and complete tears. The incidence of the rotator cuff tears increased with age; however, tendinosis occurred in younger patients. The 67% of tears in supraspinatus, 75% tears in subscapularis, and 80% tears of infraspinatus occurred after the age of 45 years. 69% cases of supraspinatus tendinosis occurred before the age of 45 years. Similar trend has been found in the previous studies. Needell et al. in a study of 100 patients found 20 out of the 22 partial tears and all complete tears occurred after age of 40 years. Tendinosis was more commonly seen in the younger population. Similar results were seen by Yamaguchi et al. and Minagawa et al. Different reasons have been given for the increase in the incidence of tears with age. Impingement secondary to the extrinsic factors such as osteophytes, downsloping acromion, and Type II and III acromion increases with age. Similarly, internal degeneration in the tendons increases with age.
Partial tear of supraspinatus tendon can be further divided into articular surface, bursal surface, or intrasubstance tears. Articular surface partial tears have been more commonly seen in the previous studies. Jacobson et al. in a study of 50 cases with rotator cuff tears with surgical correlation reported 10 cases of articular surface tears out of the total 15 partial tears. Similar results were reported by Youssef et al. and Winter et al. The common reason given for the high incidence of the articular surface tear is comparative hypovascularity seen on the articular surface of tendon as compared to the bursal surface.
Acromion has been traditionally divided into four types according to undersurface morphology. Type II acromion has been cited as most common form in the majority of the literature. Getz et al. in a study of 394 scapulae found Type II acromion in 68.5% cases and Type I in 22.8% cases. In our study, Type II acromion morphology was most commonly encountered seen in 49% cases. Variation on the acromion morphology has been associated with the rotator cuff tears, especially Type II and Type III acromion. Worland et al. in a study carried in 118 patients with suspected rotator cuff tears found that Type II and III acromion are more commonly associated with the rotator cuff tears. Mohamed and Abo-Sheisha  found that full-thickness tears were significantly associated with Type III acromion (P < 0.05). Our study showed similar results. Majority of the rotator cuff pathologies was associated with Type II and Type III acromion. 77% cases with Type II acromion and all cases with Type III acromion showed rotator cuff pathologies.
Biceps (long head) tendon showed abnormalities in 60% of the evaluated cases with tenosynovitis being the most common pathology seen in 36% cases. Rotator cuff pathologies showed positive correlation with the biceps tendon pathologies. In 81 cases of rotator cuff abnormalities, 53 cases showed biceps pathologies (P < 0.05). Chen et al. in a study of 176 patients of rotator cuff pathologies found that among the single tendon rotator cuff tears, the incidence of biceps tendon pathology was seen in the 71% cases (P < 0.001). The incidence increased when multiple tendons were involved. Similarly, Beall et al. found that tears of long head of the biceps tendon showed positive correlation with the supraspinatus and subscapularis tendon tears.
| Conclusion|| |
MRI is an accurate and sensitive modality to diagnose and characterize the rotator cuff pathologies. It provides accurate view of the associated findings such as acromion morphology and biceps pathologies and can be helpful in the future management of the rotator cuff pathologies.
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Conflicts of interest
There are no conflicts of interest.
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