Integrating Imaging of the

Shoulder in MSK practice

The Role of MRI

Cathy Barrett MCSP MPhty.st MMACP FACP

Sharon Morgans MCSP MMACP

Lecturer UCL, KCL, Coventry UniveristyCentral Health PhysiotherapyCbarrett@central-health.com

Radiology and Orthopaedic Colleagues Imperial Healthcare NHS Trust.

.

Physics

T1W image

• Fat is bright (high signal)

• Fluid is dark (lo signal)

T2W image

• Fluid is bright

• Fat is still quite bright

Proton density, Fat Suppression, STIR

Contraindications;

Claustrophobia

Metal Implant

Pacemaker

Cochlear Implants

Image Quality;1. Resolution

- Matrix

- Field of view (FOV)

- Slice thickness

2.Signal-to-Noise Ratio

(SNR)

3. Contrast

4. Artefacts

s://www.radiologycafe.com/radiology-trainees/frcr-physics-notes/mr-image-

quality

MRI VIEWS

• Coronal Views (front to back through Coronal plane)

• Saggital Views (side to side through saggital plane)

• Axial Views (Top down through horizontal plane)

• REQUESTING: Clinical information is required on your

request form for Imaging team to set up most appropriate

contrast

• REVIEWING; Need to know which sequences to view for

the anatomical tissue/pathology you are examining.

Shoulder Anatomy Checklist

Muscle

• Rotator Cuff

• SSpT and muscle

• ISpT and muscle

• SSC and muscle

• Teres minor

• Deltoid

• Biceps (Esp LHB)

• Triceps

• Pec Maj &Min, T Maj,

Bone and Joint

• Glenhumeral joint• Humeral Head• Glenoid including Labrum• Glenohumeral ligaments• Capsule

• Acromion

• ACJ

• Os acromiale

• Subacromial bursae

• Bone Marrow

• Loose bodies

• Visual Trash – LyN, Lung

MRI Technique

Normal Shoulder

MRI.coronal view

Sagittal View.

Normal MRI Axial.

Anatomy Quiz.• Can you label the diagrams?

MRI: The Rotator Cuff

• Normal Cuff

• Abnormal Cuff

• What is relevant to symptoms?

Normal Anatomy

• SST, IST, SSC, Teres Minor

• All cylindrical then flat, fan out and interdigitate at insertion on greater tuberosity of humerus, none have synovial sheath

• SST inserts onto fibrocartilage at top of gter tuberosity

• IST attaches to sup-post gter tuberosity

• Teres minor attaches to inf-post gter tuberosity

Normal SST

• Seen on more anterior coronal slices

• Horizontal orientation

• Then dives at 45 degrees

• Always found on same slice as ACJ

• Look for homogeneity tendon and muscle

Normal IST runs at 45 degree angle to posterior greater

tuberosity :Seen on posterior coronal slices and axial slices

Normal SSC

• SSC tendon best seen

on axial.

• Attaches to lesser

tuberosity.

• Blends with

transverse ligament.

Indicators Rotator Cuff

Pathology

• Bursal fluid

• Heterogeneity vs homogeneity

• Retraction of tendon

• Fatty changes in muscle belly (infiltration)

• Cystic changes at bony insertion

• Bony outlet changes

Supraspinatus:

Describe What You Can See.

How do you decide if the changes are relevant?

Same patient. What do you see?

Where are you compared to last slice?

Where are you and how do you know?

What is the diagnosis?

Discuss the options for management.

54 yr male high velocity skiing injury

Which view is this? Identify 3 abnormal features

What are the treatment options?

Security guard 46yrs Been in a scrap!

Functionally compromised- pain and weakness

What RC features are present in these scans?

Management options?

Use of Ultrasound vs MRI

• Dynamic

• Operator dependent and machine dependent

• Cheaper, faster

• Option to inject bursa, suck up soft calcium or babbotagehard calcification

• Good view:

• R cuff, bursa, muscle belly, biceps, calcification

Ultrasound;

Diagnosis and Therapeutic Intervention

• ACJ Pathology

• Capsule Hypertrophy/Intra-articular view/Ultrasound guided injection

• Lumps

• Eg Lipoma

• SCJ Pathology

• Lumps and fluid collections (Xray required; CT may be indicated)

• Sub Acromial Pain

• Rotator Cuff Pathology

• Bursal inflammation

• Calcification

US disadvantages

• Operator and machine dependent

• If inject then require MR, the MRI will be distorted

• MRI better for planning surgical intervention

Sub-Acromial and intra-articular Injection

Complications; Steroid Flare and Infection

Steroid Flare;

• Significant increase in Pain within 24-48 hours (once local

worn off)

• Can last 4 days. 20% of these will have facial flushing

• >30% incidence Fawi et al 2017

Infection; RARE

Occurs minimum several days post injection

Hot, swollen locally BUT NOT necessarily generally unwell

Degenerative Joint Disease /

Rotator Cuff pathology.

MRI Informing Management.

Degenerative Joint Disease

XR implies what?

MRI used to determine integrity

of RC and decision re prosthesis

Cuff deficient= reverse anatomy

MRI and Frozen Shoulder

• Clinical pattern indicative and Normal Xray; No need for MRI. Can proceed to Hydrodistension

• If clinically concerned….Do MRI as Greater clarity MR findings in recent years

• Capsule Inferior recess/ axillary

fold thickened

• “Halo” of Oedema

• “Ready Brek Kid”

• Rotator Interval oedema

MRI and Instability

Normal GH ligs – MGHL behind SSC

Normal ant and posterior labrum

Axial arthrogram

LEFT; MGHL seen anterior to anterior labrum

RIGHT; Different patient. Note posterior labrum is rounder than

anterior labrum

Normal variants: Buford Complex. Absent labrum, thickened MGHL

Buford Complex

Most common lesions

• BANKART

Anterior labrum torn/absent

• HILL SACHS

Posterior humeral head fracture

• BONY BANKART

Glenoid fracture antero-inferior

ANTERIOR INSTABILITY POSTERIOR INSTABILITY

Arthrogram showing anterior labral injury

ARTHROGRAM (MRA): Contrast injected and MRI

Good sensitivity and specificity

Can be sore 24-48 hours

Instability Lesions – axial MRA

• Bankart (labral bankart on arthrogram)

• Left; Anterior labral tear plus ?tear anterior periosteum. Hill Sachs defect

• Right; Tissue lying in medial joint space (completely detached) Could be labral or bone from HS defect

Bony Bankart seen on axial MRI

STRUCTURAL FINDINGS;

POSTERIOR INSTABILITY

POSTERIOR LABRAL INJURY REVERSE HILL-SACHS

CT image; Posterior dislocation

causing reverse bony Bankart

MRI FOLLOWING PREVIOUS STABILISATION

BEWARE ARTEFACT FROM SURGICAL MATERIAL:

Axial views of a patient with recurrent

instability and anterior apprehension

Orientate yourself and look for any signs

of labral pathology

Investigation Selection

Instability

MRI Good for Labral pathology if quality machine and

slices. Axial views most helpful

Good muscle differentiation

Arthrogram Better for Labral specificity and sensitivity.

Slightly increased risk infection

CT: Excellent bony construct. High Ionising radiation

dose

Arthroscopy Gold standard

WITH SPECIAL THANKS TO

OUR COLLEAGUES AT

St Marys and Imperial College

Catherine.barrett@ucl.ac.ukcbarrett@central-health.com

Cathy Barrett BSc MSc MCSP MACP FACPMember of the British Elbow and Shoulder Society

Lecturer University College Londonhttps://www.ucl.ac.uk/prospective-students/graduate/taught-

degrees/physiotherapy-studies-musculoskeletal-msc