The document provides an overview of shoulder anatomy including: 1) It describes the bones, joints, ligaments, muscles and bursae of the shoulder complex. Key joints include the glenohumeral joint (ball and socket) and acromioclavicular joint. 2) Rotator cuff muscles of particular focus are the supraspinatus, infraspinatus, teres minor and subscapularis. 3) Imaging techniques for evaluating the shoulder are discussed including radiography, ultrasound, CT, and MRI. MRI is highlighted as the most accurate for assessing rotator cuff pathology and other soft tissue injuries.

2. IntroductIon
The shoulder is one of the most sophisticated and
complicated joints of the body:
•It has the greatest range of motion than any joint
in the body
•To allow so much movement the joints need to be
'free' to move, therefore the shoulder should be
'unstable' compared to other joints of the body;
However a series of complex ligaments and muscle
help in stability.

3. AnAtomy

4. JoInts (shoulder complex)

5. Bones

7. muscles
– Deltoid - Trapezius - Rhomboids
– Levator scapulae - Serratus anterior
– Rotator cuff - Teres major
– Biceps - Pectoralis muscles

8. rotAtor cuff muscles
– S – Supraspinatus
– I – Infraspinatus
– T - Teres minor
– S- Supscapularis

9. BursAe
• Sac between two
moving surfaces
that contains a
small amount of
lubricating fluid
• To reduce friction
– Subacromial
(Subdeltoid)
– Subscapular
– Infraspinatus
Infraspinatus
Bursa

11. GlenoId lABrum
• Fibrocartilage similar to knee menisci
• Deepens the glenoid fossa

12. fIBrous cApsule
Loose for maximum movements
Gaps:
•Anteriorly: allows communication between synovial membrane
and subscapularis bursa.
•Posteriorly: allows communication with infraspinatus bursa.
synovIAl memBrAne
•Attached around the glenoid labrum.
•Lines the capsule.
•Attached to articular margins of head of humerus.
•Covers intracapsular area of surgical neck.
•Communicates with 2 bursae through gaps in capsule.
•Invests long head of biceps in a tubular sleeve.
•Glides to and fro during adduction and abduction.

13. lIGAments
• Acromio-Clavivular ligaments
– Anterior, posterior, superior, inferior
• Coracoacromial ligament
• Coracoclavicular ligaments
– Trapeziod ligament
– Conoid ligament

14. shoulder (AnterIor vIew)

15. AcromIoclAvIculAr JoInt
– Diarthrodial joint / Gliding synovial joint
– Thin capsule
GlenohumerAl JoInt
– Ball and socket synovial joint
– Very mobile
– instability
– 45% of all dislocations !!
• Joint stability depends on multiple factors
(static and dynamic stabilizers)

16. stABIlIty
• Static stabilizers
– glenohumeral ligaments, glenoid labrum and
capsule
• Dynamic stabilizers
– Predominantly rotator cuff muscles and biceps (long
head)
– Also scapular stabilizers
• Trapezius, levator scapulae, serratus anterior,
rhomboids

17. GlenohumerAl lIGAments (Ghl)
Thickenings of theglenohumeral joint capsule
Passive stabilisers of the joint.
1) Superior glenohumeral ligament
 runs from the superior aspect of the glenoid and coracoid process to the
fovea capitis just superior to the lesser tuberosity of the humerus
 stabilises the biceps brachii tendon
2) Middle glenohumeral ligament
 runs from the anterosuperior glenoid, arising just inferior to the superior
GHL, to the anterior aspect of the anatomic neck of the humerus
3) Inferior glenohumeral ligament
 Also known as inferior glenohumeral ligament complex
 runs from the inferior two-thirds of the glenoid labrum and/or neck to the
lateral humerus
 most important of the three GHLs as it prevents dislocation at extreme
range of motion and is the main stabiliser of the abducted shoulder

18. SPIRAL GLENOHUMERAL LIGAMENT
 also referred to as fasciculus obliquus 5
 runs from the infraglenoid tubercle and triceps tendon
to the lesser tubercle of the humerus where it has a joint
insertion with the subscapularis tendon
 not well-known, but consistently demonstrated on
both anatomic dissection and MR arthrography

20. rAdIoGrAphy

21. AP : Routine view
• Suboptimal view of Glenohumeral joint
• Good view of AC joint

22. AP View:
External Rotation
Greater tuberosity & soft tissues profiled and better
visualized

23. AP View:
Internal Rotation
May demonstrate Hill-Sachs lesions

24. Axillary lateral View
Good view of anterior-posterior relationship of GH joint

25. Scapular “Y” Lateral View of the Shoulder
• Shoulder impingement: to
evaluate the subacromial space
and the supraspinatus outlet

26. ultrAsonoGrAphy

27. usG
• Preferred initial modality in suspected
rotator cuff (RTC) pathologies
• > 90 % sensitive and specific for RTC
tears
• Comparable to MRI in evaluation of full
thickness rotator cuff tears
• Bony pathologies not well seen

28. • Advantages:
– no ionizing radiation,
– no contrast agent,
– relatively inexpensive,
– readily available
– Dynamic evaluation
– Guided aspiration / injection possible
• Limitations:
– Less sensitive for detecting partial thickness
rotator cuff tears
– Cannot accurately evaluate the labral-ligamentous
complex.

29. shoulder usG protocol
• Step 1 - Biceps brachii tendon, long head
• Step 2 - Subscapularis and biceps brachii tendon,
subluxation/dislocation
• Step 3 - Supraspinatus and rotator interval
• Step 4 - Acromioclavicular joint, subacromial-subdeltoid
bursa, and dynamic evaluation for subacromial
impingement
• Step 5 - Infraspinatus, teres minor, and posterior labrum

30. STEP - 1
Biceps Tendon
 Begins with Bicipital groove
 Slight external rotation of the shoulder improves visualization
 Appears as a concavity in the bright echoes originating from
the surface of the humerus in transverse view.
 Tendon of the long head of the biceps visualized as
hyperechoic oval structure within the bicipital groove.
Rotate 90° for longitudinal scan
 Important for detecting intraarticular fluid that, even when
present in small amounts, may be seen surrounding the biceps
tendon.

31. Step 1 - Biceps brachii tendon, long head
(Transverse)

32. Step 1 - Biceps brachii tendon, long head
(Longitudinal)

33. STEP - 2
Subscapularis
 Transducer moved medially relative to biceps tendon groove
 Appears as a band of medium-level echoes deep to the
subdeltoid bursa
 Subdeltoid bursa seen as thin, convex echogenic line.
 Best seen when arm externally rotated to the maximum
extent and slightly abducted

34. Step 2 – Subscapularis
(Longitudinal)

35. Step 2 – Subscapularis
(Transverse)

36. STEP - 3
Supraspinatus
 Most important aspects of USG examination of the rotator
cuff is adequate visualization of the "critical zone" (or "crucial
zone")
 It is portion of the supraspinatus tendon that begins 1 cm
posterolateral to the biceps tendon & is most susceptible to
injury.
 Failure to adequately visualize this area can cause false-
negative result.
 Viewed by moving transducer posterolaterally from the
biceps tendon groove to view it parallel (longitudinal) to its axis.
 Appears as a beak-shaped structure of medium-level
echogenicity extending from acromion to greater tuberosity.
 Bright linear echoes from subdeltoid bursa identify
superficial margin of supraspinatus tendon.

37. Step 3 – Supraspinatus
(Longitudinal)

38. Step 3 - Supraspinatus
(Transverse)

39. Step 4 - Acromioclavicular joint

40. Dynamic evaluation for subacromial impingement

41. STEP - 5
Infraspinatus
 By moving the transducer posteriorly,
 Appears as a beak-shaped soft-tissue structure attached to the
posterior aspect of greater tuberosity
 A portion of posterior glenoid labrum is seen as hyperechoic
triangular structure
 Articular cartilage of humeral head imaged as a thin,
hypoechoic layer superficial to bone surface
Teres minor
 By moving more distally along humerus.
 Differentiated from infraspinatus by oblique internal echoes.

42. Step 5 - Infraspinatus

43. ct

44. CT
• Superior to plain radiographs in
evaluation of complex fractures and
fracture-dislocations involving the head
of the humerus
• Allows planning of treatment of complex
proximal humeral fractures

45. 1) Glenoid
2) Humerus
3) Deltoid
4) Infraspinatus
5) Scapula
6) Supraspinatus
7) Clavicle
8) Subscapularis
9) Teres minor
10) Triceps
11) Pec major
12) Pec minor
13) Biceps (long)
14) Biceps (short)
15) Teres major
16) Latissimus

46. 1) Glenoid
2) Humerus
3) Deltoid
4) Infraspinatus
5) Scapula
6) Supraspinatus
7) Clavicle
8) Subscapularis
9) Teres minor
10) Triceps
11) Pec major
12) Pec minor
13) Biceps (long)
14) Biceps (short)
15) Teres major
16) Latissimus

47. 1) Glenoid
2) Humerus
3) Deltoid
4) Infraspinatus
5) Scapula
6) Supraspinatus
7) Clavicle
8) Subscapularis
9) Teres minor
10) Triceps
11) Pectoralis major
12) Pectoralis minor
13) Biceps (long)
14) Biceps (short)
15) Teres major
16) Latissimus

48. 1) Glenoid
2) Humerus
3) Deltoid
4) Infraspinatus
5) Scapula
6) Supraspinatus
7) Clavicle
8) Subscapularis
9) Teres minor
10) Triceps
11) Pectoralis major
12) Pectoralis minor
13) Biceps (long)
14) Biceps (short)
15) Teres major
16) Latissimus

49. 1) Glenoid
2) Humerus
3) Deltoid
4) Infraspinatus
5) Scapula
6) Supraspinatus
7) Clavicle
8) Subscapularis
9) Teres minor
10) Triceps
11) Pectoralis major
12) Pectoralis minor
13) Biceps (long)
14) Biceps (short)
15) Teres major
16) Latissimus

50. mrI

51. MRI
• Highly accurate for evaluation of rotator cuff
pathologies
• Indicated when further investigation of rotator cuff
pathology is needed.
• Advantages:
– No ionizing radiation
– Non-invasive
– Multi-planar imaging
– Demonstrates other lesions such as ACJ osteoarthritis
and avascular necrosis.
– Comprehensive display of soft tissue anatomy
– Demonstration of the causes for impingement
– Useful in characterization and staging of bone tumors

52. MRI Technique
-T1 and T2 FS
-Oblique Coronal -T1 and T2 FS
-Oblique Sagittal
-T2 FS and GRE
-Axial

53. Normal T1 Normal FS T2
Normal FS PD

54. Rotator Cuff (Sagittal)
Infraspinatus; Teres Minor; SubscapularisSupraspinatus;

55. Rotator Cuff (Coronal)
-Primary Plane for Evaluating
the Supraspinatus Tendon
-Musculotendinous Junction at
12:00 Position

56. Rotator Cuff (Axial Plane)
-Primary Plane for
Evaluating Subscapularis
-Infraspinatus
Located Posteriorly

57. Rotator Cuff (Coronal)
- Infraspinatus
- Located Posteriorly
- Slopes upward
-Subscapularis
- Located Anteriorly
- Multi-slip tendon

58. shoulder AnAtomy

59. An axial T1 MRI
image at the top of
the shoulder.
Here fat
suppression is used
to increase the
conspicuity of
contrast

60. This is a lower sequential
axial image just above the
shoulder joint.
What muscle (arrows) and
tendon (arrowheads) are
these?
 supraspinatus muscle
and tendon.

61. As we go down contrast
becomes visible.
 Note the anterior,
lateral and posterior
heads of the deltoid.
Anterior
Lateral
Posterior

62.  This image is further
inferior, do you see the
coracoid process?
Remember this is an
anterior structure.
 Do you remember
the attachments onto
the coracoid process?
 The coracobrachialis
and the short head of the
biceps muscle. Also the
pectoralis minor
attached to the coracoid
process.

63. Can you find the
subscapularis tendon on
this image?
What articular part of
the scapula articulares
with the humerus?
 This is the glenoid

64.  Can you find the
fibrocartilagenous glenoid
labrum?
Anterior
labrum
Posterior
labrum
 What is the function of
the glenoid labrum?
 To add surface area and
provide stability to the
glenohumeral joint.
 Where does the labrum
tear with an anterior
shoulder dislocation?
 Anterio-inferiorly

65.  Do you see this patients’
anterior inferior labral tear?
 There is high signal
between the anterior and
inferior labrum and the
bony glenoid characteristic
of a labral tear. This case
was kind of subtle, so the
patient was put in an
abducted externally rotated
arm position to displace the
torn labrum.
 Here the contrast
between labrum and
glenoid is better visualised

66.  This is the final image in this
axial set. What is this black
structure between the greater
and lesser tuberosities
surrounded by contrast?
 Long head of the biceps
tendon in the bicipital groove.
It is common to have
contrast surround this
structure as it passes through
the shoulder joint before it
inserts onto the suoperior
labrum.

67. This is a coronal
proton density
image starting in
the posterior
aspect of the
shoulder.
 What bone is
marked by the
arrows?
 acromion
 What posterior
rotator cuff muscle
are marked by the
upcoming arrows?
T eres minor
 Infraspinatus

68.  What posterior
rotator cuff tendon
is marked by the
arrows?
 Infraspinatus
tendon

69.  What is this
ligament attaching
onto the acromion?
 Coracoacromial
ligament
 What lateral
muscle is this?
 Deltoid

70.  Take a look at
this mid coronal
image though the
shoulder joint. You
see the glenoid and
humerus as if you
are looking at a
frontal x-ray
Can you find the
supraspinatus
muscle?
 How about the
trapezius muscle?

71.  As we are more
anterior here, can
you trace the
intraarticular
portion of the long
head of the biceps
tendon as it inserts
onto the superior
labrum?

72.  On this anterior
image can you find
the short head of
the biceps tendon
as it attaches to
the coracoid and
the subscapularis
tendon?
 Short head of
biceps tendon
 Tendon of
subscapularis

73.  Can you see the
neurovascular
structures in the
anterior aspect of
the axilla?

74. shoulder pAtholoGIes

75. Pathologies
• Rotator Cuff
• Biceps tendon
• Labrum and capsule
• Osseous structures
• Arthritis
• Neural impingement
• Tumors
• Miscellaneous

76. Rotator cuff
• Tendinopathy
• Partial tears
• Full thickness tears
• Calcific tendinitis
• Parsonage Turner
syndrome

77. Rotator cuff tendinopathy
Also known as -
•Rotator cuff tendinosis
•Definition – collagenous
degeneration of rotator
cuff tendons, most
commonly supraspinatus
(SST)

78. MRI
• T1W – thickened heterogeneous tendons with
intermediate signal intensity
• T2W – low to intermediate signal
• FS PD and STIR – heterogeneous tendons with
increased signal intensity
– Hyperintense effusion (glenohumeral joint)
– Hyperintense bursitis ( subacromial / subdeltoid )
• Type III (hooked) acromion
• MR arthrography – no cuff defect identified

80. Differentials
• Partial tear –
– T2 (without fat sat) shows diminished / intermediate signal
intensity in tendinosis as compared to a hyperintensity of a
true cuff tear
• Calcific tendinitis –
– thickened tendon with decreased signal on all sequences
– Hyperintense surrounding edema on T2WI
• Intratendinous cyst –
– Well defined , usually oval
– Hyperintense cyst on T2WI
• Magic angle artifact –
– Increased signal at curved portion of tendon
– 55 degrees to external magnetic field
– Affects biceps and SST tendon and labrum

81. Rotator cuff tears
CAUSES–
• Intrinsic factors:
– Vascular
– Degenerative ( age-related)
• Extrinsic factors:
– Impingement
• Acromial spurs
• AC joint osteophytes
– Repetitive use
• Traumatic (e.g. a fall or trying to catch or lift a heavy
object)

82. Symptoms
• Pain radiating to deltoid insertion or biceps
• Insidious progression of pain
• Night pain
• Popping noises
• Weakness
• Could be asymptomatic

83. Signs
• Painful arc
60 degrees - 120 degrees elevation
• Drop arm test
• Restricted internal rotation
• Subacromial crepitus
• Weak RC muscles
• Inability to lift the shoulder
• Palpation of cuff defect and wasting

84. TYPES –
•Partial –
– supraspinatus most common
– Types – bursal surface
interstitial (not seen on arthroscopy)
articular surface
•Complete –
– supraspinatus most common
– Extends from bursal to articular surface
– Partial more painful than complete tears !!!!

85. Partial tears

86. Radiographic findings
Findings associated with impingement and
degenerative changes
•Acromial spurs
•Type III (hooked) acromion
•Humeral head arthritic changes at greater
tuberosity
•AC degenerative changes

88. MRI
Incomplete defect in tendon filled with joint fluid +/- granulation
tissue
• T1WI –
– thickening of RTC tendons
– intermediate signal
– Calcifications
– hypointense bone impaction (Hill-Sachs) in case of anterior
dislocation
• T2WI –
– Fluid signal intensity filling an incomplete gap in tendon
– Fluid in subacromial bursa
– Increased signal on FS PD (sensitive for partial tears)
– Retraction and degeneration of tendon edges (bursal or articular)

89. • PC T1 –
– enhancement of the granulation tissue
• MR arthrography –
– Contrast may fill the tear if articular surface of the
tendon communicates with joint

92. Articular & bursal surface Partial thickness tear

93. Bursal surface Partial thickness tear

94. Intramuscular cyst and Partial thickness tear

95. Partial-thickness tear seen better on
angled oblique sagittal views

96. Rim-rent or partial-thickness articular-surface tendon
avulsion (PASTA) tear

97. USG
• Decreased echogenicity and thinning in
affected region
• Loss of convexity of tendon / bursa interface
in bursal surface tears
• Calcific foci in tendons

98. Partial Thickness Tear

99. The transverse ultrasound scan along the fibers of the SSC
demonstrates a large defect at the insertion of the SSC tendon
& Corresponding axial T1-weighted MR arthrogram
demonstrates a beautiful correlation of the SSC tear visible on
the ultrasound image.
Subtotal tear of the subscapularis (SSC) tendon

100. Subtotal tear of the subscapularis (SSC) tendon
A parasagittal ultrasound scan perpendicular to the fibers of
the SSC tendon also demonstrate the defect in the SSC tendon
& Corresponding parasagittal T1-weighted MR arthrogram
shows again a beautiful correlation of the SSC tear visible on
the ultrasound image

101. Articular partial thickness tear
of the supraspinatus tendon
on longitudinal ultrasound
scan with internal rotation of
the arm , transverse US scan &
corresponding coronal T1-
weighted fat suppressed MR
arthrogram

102. Differentials
• RTC tendinopathy
• Full thickness tear without visible
communication – closed by granulation
tissue / fibrosis / adhesions
• Intratendinous cyst – can be associated with
partial tears
• Calcific tendinitis – hypointense on all
sequences

103. Full thickness tears

104. Full thickness tear

105. Full thickness tears
Etiology – similar to partial tears
Associated with –
– Hill Sach’s deformity (anterior dislocation)
– Biceps tendinosis / tears / SLAP lesions with
micro instability

106. Radiography
• Acromial spurs
• Type III (hooked) acromion
• Humeral head arthritic changes at greater
tuberosity
• AC degenerative changes
• Superior humeral head migration

108. Detecting a torn Rotator Cuff Tendon using an Arthrogram
Inject dye into joint to see if it leaks out where the rotator
cuff tendon is supposed to be

109. MRI
• T1WI
– Thickened indistinct tendon
– Tear edges not delineated on T1
– Calcifications (i/c/o calcific tendinitis)
• T2WI
– Hyperintense fluid signal filling a gap in the tendon (T2 and
FS PD)
– Bald spot sign – hyperintense fluid ‘bald spot’ within
hypointense tendon
• On sag and axial T2
– Fluid in subacromial bursa
• Retraction and degeneration of tendon edges
• Sometimes associated with fatty atrophy of muscles (fat
signal on T1)

110. Full-thickness tear

111. Bald spot sign

112. USG
• Focal tendon interruption
• Fluid filed gap (hypoechoic)
• Loss of convexity of tendon / bursa interface
• Tendon retraction
• Uncovered cartilage sign

113. Normal supraspinatus
Longitudinal & Transverse US scan
Note the convex curvilinear course
when it passes over the humeral
head.
Small full-thickness tear of the
supraspinatus tendon
Longitudinal & Transverse US scan Hypo
echogenicity demonstrates the tear, note
also the concavity of the outer contour

114. Full-thickness tear of the
supraspinatus (SSP) tendon
on longitudinal ultrasound
(US) scan & transverse US
scan with a corresponding
coronal T2-weighted fat
suppressed MR arthrogram

115. -Wiener and Seitz
USG Rotator cuff tear grading
Tear Category Imaging Features
Normal Normal
Partial-thickness
Hypoechoic or dominant
echogenic focus
Small full-thickness < 1 cm
Large full-thickness 1-3 cm
Massive
(> 3 cm) With or without
cuff arthropathy

116. Massive Tear
•Greater than 3 cm.
•Nonvisualization of the rotator cuff tendons.
•Deltoid/ subacromial-subdeltoid (SA-SD) bursa apposed
to the humeral head.
•Passive humeral motion is often useful in evaluation, as
movement of the greater tuberosity is not accompanied
by motion of the supraspinatus.

117. MRI Rotator cuff tear grading
- Dr Yuranga Weerakkody and Dr Frank Gaillard et al.
•GRADE 0 : normal
•GRADE I : increased T2 signal with normal morphology
•GRADE II : increased T2 signal with abnormal morphology
(thickening, or irregularity of the tendon)
•GRADE III : defined tear (e.g. partial or full thickness,
complete or incomplete)

118. RotatoR inteRval teaRs

119. Rotator interval tears
• What is rotator interval ??
– Tunnel through which long head of biceps travels
from its origin at the supraglenoid tubercle
• Rotator interval tears – tears in the capsule
between the supraspinatus and subscapularis
tendons
• Can be classified as subtype of RTC tears

120. MRI
• T1 –
– Thickened rotator interval
– Biceps tendinosis and subluxation
• T2 –
– Visible tear in rotator interval
– Associated tear of SST may be present
– FS PD sag images are useful to detect abnormal fluid extension
across rotator interval
• MR arthrography –
– Leakage of contrast through the tear in RI
– Intact SST and SSC

122. inteRnal impingement

123. Internal impingement
• Definition - Degeneration and tearing of posterior SST
and anterior infraspinatus tendons (undersurface /
articular surface) due to impingement by postero-
superior labrum and humeral head
• Postero-superior glenoid impingement (PSGI)
• Overhead throwing activities – athletes (throwers)
• Dynamic compression – occurs during abduction (> 120
degrees), retropulsion and extreme external rotation
(ABER)

124. MRI
• T1 –
– Thickened posterior SST and anterior IST (tendinosis)
– Postero-superior labral irregularity (fraying)
– Tear in postero-superior labrum (can be avulsed)
– Postero-superior humeral head irregularity
• T2 –
– Hyperintense signal on articular surface of posterior SST
and anterior IST
– Hyperintense signal (FS PD) in postero-superior humeral
head, humeral head chondromalacia
– Fraying +/- tear of PSGL

125. Synovitis, labral fraying, sclerosis at
posterosuperior glenoid, cystic changes in
posterolateral humeral head
Axial FS PD

126. • MR arthrography –
– Postero-superior labral fraying / tear
demonstrated by contrast outline
– ABER imaging shows undersurface tears
– Chondromalacia outlined by contrast

127. • Best diagnostic clue - triad of damage at
1. Undersurface of Rotator cuff
2. Postero-superior labrum
3. Humeral head
• Differentials –
– Subacromial impingement (history differs)
– SLAP without RTC pathology

128. Rotator cuff calcific tendinitis

129. Rotator cuff calcific tendinitis
• Calcium Hydroxyapatite deposition disease (HADD)
• Calcifying bursitis
• Not typical Ca++ of degenerative disease of tendons, but crystalline Ca+
+
• Pathology – deposition of Calcium Hydroxyapatite in RTC tendons
• Etiology – Avascular change, trauma, abnormal Ca++ metabolism
• Housewives and clerical workers more affected
• Location – SST > IST > TM > SSC
• Peri-articular soft tissues like capsule, bursae may be involved

130. Stages / classification
(Moseley)
• Silent
• Mechanical – intra bursal or sub bursal rupture
Physical restriction of movements
• Adhesive peri-arthritis – tendinitis
bursitis

131. • Radiography
– Calcific deposits
– Internal rotation demonstrates posterior tendons
well (IST and TM)
– Axillary view and scapula ‘Y’ view helpful

132. CT
•Better localization of calcium deposits
•Dense, granular, well demarcated
calcifications

133. MRI
• Globular decreased signal mass (on all pulse
sequences) in RTC tendons
• Often surrounded by edema / partial tear
(hyperintense)
• No involvement of articular cartilage
• Hydroxyapatite deposits may have exactly same
signal as normal cuff tendons
• T2*GRE is helpful as calcifications bloom and
increase sensitivity

134. Calcific tendonitis

136. Axial PD

137. Differentials
• Degenerative calcification in torn tendon
– Usually smaller calcifications
– In older age group
– Different chemical composition
• Loose bodies
– Chondral defects seen
– Articular OA changes
• Osteochondromatosis

138. Parsonage - Turner syndrome

139. Parsonage - Turner syndrome
• Idiopathic denervation of the shoulder musculature
• More than one nerve may be involved
• Mainly affects the LMN of the brachial plexus and / or individual
nerves or nerve fibers
• Etiology –
– Immune mediated reaction against nerve fibers
– Trauma, infection, surgery, vaccination, systemic illness
• Pathology –
– Degenerative changes in affected muscles
– Early and subacute – swollen muscle belly
– Chronic - fatty atrophy

140. CT
• Acute / subacute cases – mildly increased bulk
of muscles
• Chronic cases – fatty density in involved
muscles

141. MRI
• MRI abnormalities appear usually after 2 weeks
• T1 –
– Early – decreased signal (edema)
– Chronic – muscle atrophy with streaky fat signals (fatty
atrophy)
• T2 –
– Early – increased signal intensity, enlarged muscle bulk
– Chronic – atrophic muscles
– Nerve distribution pattern +/-
• PC T1 – muscle belly enhance in early stages

143. Differentials
• Traumatic neurapraxia
• Non specific myositis ( usually nerve pattern
not followed)
• Direct trauma to the muscle belly (history)

144. Pathologies
• Rotator Cuff
• Labrum and capsule
• Biceps tendon
• Osseous structures
• Arthritis
• Neural impingement
• Tumors

145. Labrum and capsule
• Labral cyst
• Antero-superior
variations
• Adhesive capsulitis
• Bankart
• Perthes
• ALPSA
• GLAD
• HAGL
• IGL
• Bennett

146. Labral cyst

147. Labral cyst
• Cyst arising from labral / capsular tear / capsular
diverticulum
• Etiology – cyst arising due to break in integrity of
joint
• 3-5 % of labral tears associated with labral cysts
• Slow growing, original tear may heal
• Associated abnormalities –
– Instability (non healed)
– SLAP (superior labrum anterior to posterior)
– Denervation of SST and IST (compression)

148. MRI
Common location – adjacent to postero-superior labrum
funneled between SST and IST (path of
least resistance)
•T1 –
– Decreased signal intensity cystic mass
•T2 –
– Hyperintense cystic lesion
– Often multiloculated
– Arising from / immediately adjacent to the labrum / capsule
– Degenerative changes in SST / IST (suprascapular nerve)
– Labral tear
•MR arthrogrpahy –
– Cyst filled with contrast

150. Differentials
• Neoplasm
– Internal enhancement
– Not associated with labral / capsular tear
• Normal vessel –
– plexus in suprascapular notch
– Can be enlarged in CHF

151. Antero-superior labrum variations

152. Antero-superior labrum variations
Congenital anatomical variations
May be developmental
 Sub-labral foramen
 Buford complex (BC)
 Labral types
 Synovial recesses

153. Sublabral foramen
• Relative lack of attachment of anterosuperior
labrum to the glenoid rim in anterior superior
quadrant
• MRI –
– Hyperintense fluid signal (mostly linear) on T2
undermining the antero-superior labrum

154. DIFFERENTIALS
-SLAP lesions
-Bankart’s lesion: Below the equator (Antero-inferior)
-Foramen of Weitbrecht:
• A small opening in the glenohumeral joint capsule
between superior and middle glenohumeral
ligaments and is seen communicating with the
subtendinous bursa of subscapularis muscle.
-Foramen of Rouviere :
• Rarely seen space in the shoulder joint capsule between
middle and inferior glenohumeral ligaments and it may
communicate with the subcoracoid recess (inferior
subscapularis recess).
-Both should not be confused with an acquired defect.

155. Axial FS PD - anterior labrum directly
attached to the hyaline cartilage

156. Buford complex
• Complete absence of antero-superior labrum
+
• Thick cord-like middle glenohumeral ligament
(MGHL) anterior to the anterosuperior glenoid
rim

158. Buford complex

159. Buford Complex

160. Labral types
Variations in labral attachment patterns
•Superior wedge labrum
•Posterior wedge labrum
•Anterior wedge labrum
•Meniscoid labrum

161. Synovial recesses
• Visualized on sag images as capsular variations
relative to MGHL

162. Adhesive capsulitis

163. Adhesive capsulitis
• Frozen shoulder
• It is characterized by pain and restriction of all
movements of the shoulder (global stiffness)
• Pathology - Inflammation of the inferior shoulder
capsule (axillary pouch) causing limited range of motion
• May accompany other disorders like impingement
(secondary adhesive capsulitis)
• Usually self limiting (typically begins gradually, worsens
over time and then resolves but may take >2 years to
resolve)

164. • Risk factors:
– DM (esp. insulin dependent)
– Following injury or surgery to the shoulder
– Hypo and Hyperthyroidism
– High cholesterol
• Stages:
– Pain (freezing stage)
– Stiffness (frozen stage)
– Resolution (thawing stage)

165. Radiography
• Plain radiography not useful
• Arthrography –
– Contracted irregular capsule
– Decreased volume +/-
– Over-injection may leading to capsule rupture
may be therapeutic !!! (improved ROM)

166. MRI
• T1 –
– Thickened indistinct capsule margins
• T2 –
– Thickened capsule (> 3mm on coronal images)
– Increased signal
– Thickening more conspicuous on FS PD, STIR and T2*GRE
– FS more sensitive for capsular edema and synovitis
– Sagittal images for rotator interval
• MR arthrography –
– Capsule enhances diffusely, acutely
– Restricted capsular volume

169. Bankart lesion

170. Bankart lesion
• A common complication of anterior shoulder
dislocation and are frequently seen in association with
a Hill-Sachs lesion
• Result from detachment of the anterior inferior gleno
humeral labral complex (IGHLC) from the underlying
glenoid as a direct result of the anteriorly dislocated
humeral head compressing against the labrum.
• It may be labral only ("soft Bankart"), or involve the
bony glenoid margin (impaction fracture) and called
a "bony Bankart".
• Additionally, labral tears may also be present.
• Occurs after initial anterior dislocation in young ( > 90%
cases are < 40 years)

171. Radiography
• Subglenoid / subcoracoid dislocation
• Glenoid rim fracture
CT
• Arthrography – contrast extending into the
labral tear

172. MRI
• T1 –
– Hypointense edema / sclerosis at antero-inferior glenoid
– Glenoid rim fracture (sag and axial more useful)
• T2 –
– Labrum – torn with hyperintense fluid, within or underlying
labrum
– fracture line at glenoid rim
– Fracture at postero- lateral humeral head
– Thickened and hyperintense IGHLC (acute dislocation)
– ABER view better for visualization
• T2*GRE – greater sensitivity for abnormal intra-labral
signal as compared to FS PD or PD

173. A small bone fragment is displaced from the inferior aspect of the glenoid
consistent with a bony Bankart lesion. There is also subtle compression
deformity of the superolateral humeral head consistent with a Hill-Sachs lesion.
Both these lesions are the result of previous anterior shoulder dislocation. This
patient had a history of recurrent dislocations.

176. Perthes lesion

177. Perthes lesion
• Bankart variant (uncommon 5-10 % of Bankart lesions)
• It is one of the types of the anterior glenohumeral injury
in which the anterior inferior labrum is torn and lifted
from the edge of the glenoid but is still attached to the
intact lifted periostium from the anterior aspect of the
glenoid.
• Although the labrum may be normally positioned,
functionally it no longer provides any stability to the
humeral head, mainly as a result of impairment of the
normal stabilizing influence of the inferior glenohumeral
ligament.
• Etio-pathology similar to Bankart lesion

178. MRI
• T2 –
– Subtle linear increased signal intensity at the base of
usually non-displaced labrum
– Bankart fracture
– Redundant hypointense periosteum
• STIR –
– provides improved contrast for visualization of medially
stripped scapular periosteum
• MR arthrography – in ABER (arm placed behind the
head)

180. ALPSA lesion

181. ALPSA lesion
Anterior Labro-ligamentous Periosteal Sleeve Avulsion
•It is similar to a Bankart lesion, in that it too is usually due to anterior
shoulder dislocation and involves the anterior inferior labrum.
•Unlike the Bankart lesion in which the labrum is avulsed from the
underlying glenoid, in an ALPSA lesion the mobilised labrum remains
attached to the periosteum which overlies the glenoid (thus sleeve).
•The clue is the medial displacement and inferior shifting of the IGHL
complex.
•Hill-Sachs lesion may be associated.
•It can heal (as opposed to Bankart which do not), however it can do so in
an abnormal position requiring identification and early surgical repair.
•Thus three Components -
– Anterior IGHLC avulsion from antero-inferior glenoid
– Intact periosteum
– Medial displacement and inferior shift of the anterior IGHLC

182. MRI
• T2 –
– Medial displacement of IGHLC on axial and coronal
images
– Hyperintense in acute cases
– Hypointense in chronic cases
– Hyperintense edema and hemorrhage in joint capsule
and adjacent soft tissues
• MR arthrography –
– Medial and inferior displacement of labrum
– Chronic cases with re-synovialisation show minimal
displacement

184. GLAD lesion

185. GLAD lesion
Glenoid Labrum Articular Disruption
•Definition - Partial tear of anterior glenoid labrum
with adjacent articular cartilage defect
•Young physically active patients
•These lesions do not tend to be associated
with shoulder instability.
•Pain on IR and adduction

186. MRI
• Irregular increased signal intensity on T2 / FS PD
within the anterior labrum and adjacent hyaline
articular cartilage
• Labral tear is typically not detached
• Chondral defect well seen on FS PD (not well seen
on T2)
• MR arthrography –
– Contrast filling the labral tear
– Contrast may fill the chondral defect
– ABER – demonstrates partial labral tears by placing
stress on capsular ligamentous attachments

189. HAGL
• Humeral Avulsion of Glenohumeral Ligament
• Inferior GHL involved
• CT arthrography – extravasation of contrast through humeral
interface defect into anterior para-humeral soft tissue
• MRI –
– discontinuous capsule at humeral interface (anatomic neck
attachment of IGL)
– Capsule assumes ‘J’ shape on coronal images (normal axillary
pouch has ‘U’ shaped contour )
• MR arthrography – extravasation of contrast inferior to
axillary pouch

191. Bennett lesion
• A Bennett lesion is mineralization
of the posterior band of
the inferior glenohumeral
ligament as a result of extra-
articular posterior capsular
avulsion injury.
• Dystrophic / heterotopic
ossification
• Throwing athletes (javelin,
baseball)

192. • Radiography –
– Mineralization adjacent to posterior glenoid
– Better visualized on axillary view
• CT arthrography –
– Posterior labral tear
• MR –
– Crescent shaped areas of ossification
– Adjacent to posterior labrum
– Labral tear
– T2*GRE show blooming
– MR arthrography – posterior labral tear

194. Posterior labral tear
• Reverse Bankart (detachment of posteroinferior labrum
with avulsion of posterior capsular periosteum)
• POLPSA (Posterior Labrocapsular Periosteal Sleeve
Avulsion) : occurs when an Intact posterior scapular
periosteum and posterior labrum becomes stripped off
leading to redundant recess
• Secondary to posterior dislocation
• Posterior band of IGHLC ‘weak link’ among static stabilizers
in most shoulders
• Radiography and CT –
– Posterior glenoid rim fracture
– Trough sign – reverse Hill Sachs on anterior humerus creating a
trough / defect
– Lesser tuberosity avulsion fracture

196. Pathologies
• Rotator Cuff
• Labrum and capsule
• Biceps tendon
• Osseous structures
• Arthritis
• Neural impingement
• Tumors

197. Biceps tendon pathologies

198. Tendinosis

199. Tendinosis
• Degeneration of long head of biceps
• Long head of biceps –
– LHBT originates at supra glenoid tubercle
– Passes through the antero-superior joint
– Enters the humeral bicipital groove
• Chronic micro-trauma
• Acute trauma (rare cause)
• Accompanies RTC disease (especially impingement)
• Common with subacromial impingement (30-60%
association)
• Biceps tenosynovitis may accompany

200. • Radiography - Sclerosis at the superior aspect
of bicipital groove (chronic cases with
instability)
• USG –
– Thickened hypoechoic tendon
– Tears often directly visible
– Allows dynamic evaluation

201. MRI
• T1 –
– Thickened intermediate signal intensity tendon
– SST tendinopathy
• T2 –
– Thickened (> 5 mm), irregular frayed tendon
– Increased signal
– FS PD and PD more sensitive for tendinosis
– T2 more sensitive for fraying / tears
– SST tendinopathy
• MR arthrography – thickened filling defect
(enlarged tendon)

203. Biceps tendon tear

204. Biceps tendon tear
• Tendinosis predisposes
• Associated with SST tear
• Distal tendon edge may retract into upper arm

205. • CT arthrography –
– Bicipital groove filled with contrast
– Absence of normal ‘filling defect’
• MRI –
– Irregular stump at superior aspect of joint
– Partial or complete hyperintense fluid gap in the
tendon (T2)
– Synovitis (PD)

207. SLAP lesions

208. SLAP lesions
• Superior Labrum Anterior to Posterior lesions /
tears
Classification –
• type I: fraying of the superior labrum
• type II: detachment of the superior labrum and biceps anchor
from the underlying superior glenoid
– in younger patients (<40 years of age) these are associated with Bankart
lesions
– in older patients (>40 years of age) they are associated with rotator cuff
tears
• type III: bucket handle tear of the superior labrum without
extension into the long head of biceps tendon
• type IV: bucket handle tear of the superior labrum with
extension into the long head of biceps tendon
 SLAP V to X have also been classified

216. MRI (T2)
• SLAP I –
Intermediate to hyperintense labral degeneration without labral tear
Represents intra substance degeneration
Can be age related normal finding
• SLAP II –
Linear hyperintense fluid signal between superior labrum and superior
pole of glenoid (> 5 mm displacement of labrum and biceps anchor on
coronal images)
• SLAP III –
Identify fragmented superior labrum into two separate components on
sag and cor images through BLC )
Bucket handle tear through the meniscoid superior labrum
• SLAP IV –
Split of the biceps tendon with hyperintense linear longitudinal tear with
avulsion

217. SLAP I SLAP II

218. SLAP III

219. SLAP IV

220. Biceps tendon dislocation

221. Biceps tendon dislocation
• Biceps instability
• Definition – dislocation of long head of biceps
tendon from bicipital groove
• Etiology –
– Due to disruption of stabilizing ligaments (RTC tears)
– SSC and coracohumeral ligament are major stabilizers
of biceps
– Shallow bicipital groove predisposes

222. MRI
• T1 –
– Increased signal intensity fat fills the bicipital groove
• T2 –
– Tendon not in groove
– Mostly displaced medially
– Flattened / thickened (if previous tendinosis)
– SSC partial / complete tear
• T2*GRE – more sensitive for visualization of hypointense
biceps fiber
• MR arthrography – empty groove, tendon sheath filled
with contrast

224. USG
• Empty groove
• Displaced biceps tendon hypoechoic and
edematous
Best diagnostic clue –
• Empty bicipital groove with oval structure
outside the groove with hypointense signal on
all pulse sequences (MRI)

225. Pathologies
• Rotator Cuff
• Labrum and capsule
• Biceps tendon
• Osseous structures
• Arthritis
• Neural impingement
• Miscellaneous

226. Osseous structures

227. Osseous structures
• Subacromial impingement
• Os acromiale
• AVN
• Dislocation
• Osteochondral injuries

228. Subacromial impingement

229. • Describes a condition in which the supraspinatus and bursa
are pinched as they pass between the head of humerus
(greater tuberosity) and the lateral aspect of the acromion

231. Etiology –
•Primary extrinsic - Subacromial spur, AC OA
•Type III (hooked) acromion
•Lateral down sloping of anterior acromion
•Os acromiale
•Secondary extrinsic – no osseous abnormality of
coracoacromial arch

232. Radiological findings
Plain X-rays:
– Acromial spurs
– AC joint osteophytes
– Subacromial sclerosis
– Greater tuberosity cyst

234. • Type of acromion:
I : flat
II : curved
III: hooked
IV: Reverse curve

236. Acromial Types
Type I

237. Acromial Types
Type II

238. Acromial Types
Type III

239. Acromial Types
Type IV

240. MRI
• Hooked acromion on sagittal images with
decreased subacromial outlet
• Lateral down sloping seen on coronal images
• Subacromial space < 7 mm considered increased
risk
• Changes of RTC tendinopathy
• Partial tears may be seen
• Bursitis
• Thickened coracoacromial ligament

242. Coracoid Impingement
-Normal Coracohumeral
Distance is 11 mm
-Narrowed C-H Distance can
Impinge on Subscapularis

243. Os acromiale

244. Os acromiale
• Unfused acromial ossification center
• Normally fuses by 25-30 years
• Mature bone with synchondrosis between os
and acromion
• +/- mobile distal acromion
• Can cause impingement
• Rx – conservative, preacromian excison,
stabilization

245. Types
• Basi-meta (type C)
• Meta-meso (type A)
• Meso-pre (type B –
most common)

247. MRI
• Age > 25-30 years
• Unfused bony fragment
• Corticated structure with medullary fat in it
(hyperintense)
• Hypointense sclerosis at its margins
• Pseudo double AC joint (axial and cor)
• T2*GRE – unfused ossification demarcation
(hyperintense)

248. Double AC joint sign

249. Avascular Necrosis

250. AVN
• AVN / osteonecrosis
• It is ischemic death of cellular elements of bone
and marrow
• Etiology – steroids, alcohol, smoking, trauma,
collagen vascular diseases, arteritis, storage
disorders (Gaucher’s), idiopathic
• 2nd
most common (after femoral head)
• Also known as ‘Hass disease’
(Note : Panner disease is AVN of capitulum of humerus)

251. Radiography
• Arc like subchondral fracture (crescent sign)
• Articular collapse (step sign)
• Fragmentation
• Subchondral lytic sclerotic areas
• Subchondral cysts
• Deformed humeral head
• Secondary degenerative changes

252. AVN

253. Class Description
I Normal (can be seen on MRI)
II
sclerosis in superior central
portion of the head
III
crescent sign - caused by
subchondral bone collapse; may
have mild flattening
IV
significant collapse of humeral
articular surface.
V degenerative joint disease.
Cruess X-ray Classification of AVN Humeral Head

254. MRI
• Supero-medial part of head most commonly involved
• Serpiginous hypointense lines (T1)
• Double line sign – increased signal in the center of the
line (vascular granulation tissue) with decreased signal
on both sides (T2 and T2*GRE)
• Non specific edema
• Subchondral collapse and cysts
• FS PD – more sensitive for ischemic edema in acute cases

255. • PC T1 – the granulation component of ‘double
line sign’ may enhance
• MR arthrography – contrast extend into the
necrotic bone
Best diagnostic clue –
 Supero-medial involvement
 Double line sign on T2W

257. Osteochondral injuries

258. Osteochondral injuries
• Definition - Injury to articular hyaline cartilage
+/- underlying bone fracture, bone trabecular
injury or associated reactive stress response
• Tidemark zone is the weakest part of articular
cartilage – between overlying cartilage and
subchondral bone
• Rotational forces – direct trauma – cause
cartilage injury – secondarily involve the
underlying bone

259. MRI
• T1 –
– Subchondral sclerosis and edema
• T2, FS PD and STIR –
– Increased signal in articular cartilage
– Underlying bone edema (hyperintense)
• T2*GRE – only sensitive to large chondral defects
• MR arthrography – contrast fills the chondral defect
Best diagnostic clue –
• Increased signal in articular cartilage

260. ‘Outerbridge’ classification of articular cartilage
injuries
• Grade 0 – normal
• Grade 1 – chondral softening and swelling (increased
signal on FS PD)
• Grade 2 – partial thickness defect, not reaching
subchondral bone / < 1.5 cm in max dimension
• Grade 3 – just reaching upto the subchondral bone / >
1.5 cm
• Grade 4 – exposed bone / full thickness cartilage loss

262. Pathologies
• Rotator Cuff
• Labrum and capsule
• Biceps tendon
• Osseous structures
• Arthritis
• Neural impingement
• Miscellaneous

263. Arthritis

264. Osteoarthritis
Glenohumeral joint
Acromio-clavicular joint (AVC)
• Relatively uncommon compared to
impingement
• Older patients
• Younger patients (post trauma / post surgery)

265. Radiography
• Joint space narrowing
• Osteophytes
• Subchondral cysts and sclerosis

266. Shoulder Arthritis

267. MRI
• Subchondral cyts
• Osteophytes (marrow signal extends into it)
• Generalized thinning of hyaline cartilage, with
occasional focal defects
• Synovitis
• Loose bodies
• Posterior glenoid wear leads to increased
retroversion of glenoid
• PC T1 – synovial enhancement in synovitis

268. Rheumatoid arthritis
• Synovium – articular cartilage – subchondral bone
• Marginal erosions (more at greater tuberosity)
• Bilateral symmetrical involvement
• Diffuse synovial thickening
• Joint effusion
• Bone erosions
• Loss of joint space not prominent
• Mild superior migration of humeral head (RTC rupture)
– decreased space between HH and acromion
• Clavicular erosions predominate at AC joint
• Tapered and resorbed distal clavicle (chronic cases)

269. Pathologies
• Rotator Cuff
• Labrum and capsule
• Biceps tendon
• Osseous structures
• Arthritis
• Neural impingement
• Miscellaneous

270. Neural impingement

271. Quadrilateral space syndrome
•Entrapment neuropathy (compression) of axillary nerve in
quadrilateral space
•Boundaries –
•Superiorly – teres minpr
•Inferiorly – teres major
•Medially – long head of triceps
•Laterally – humerus
•Best diagnostic clue –
•Increased signal in teres minor and deltoid on FS PD or STIR
(denervation)
•Streaky decreased signal intensity (fibrosis)

272. Suprascapular / Spinoglenoid
notch
• Impingement of suprascapular nerve
• Location -
– SSN at superior glenoid
– SGN at posterior glenoid
• Best diagnostic clue –
• Increased signal in SST and IST on FS PD or STIR
(denervation)
• Streaky decreased signal intensity (fibrosis)

273. Miscellaneous Pathologies
• Dislocations
• Fractures
• Tumors
• AC separation

274. Dislocation
Types
According to the direction:
•Mostly Anterior (Subcoracoid) > 95 % of dislocations
•Posterior Dislocation occurs < 5 %
•True Inferior dislocation (luxatio erecta) occurs < 1%
According to the mechanism:
•Traumatic
•Non traumatic dislocation may present as Multi
directional dislocation due to generalized ligamentous
laxity. It may become painless  habitual

275. Glenohumeral Joint
• Most common
dislocated joint
• Lacks bony
stability
• Composed of:
– Fibrous capsule
– Ligaments
– Surrounding
muscles
– Glenoid labrum

276. Anterior Shoulder dislocation
• Usually also inferior
• Bankart’s Lesion

277. Mechanism of anterior shoulder
dislocation
• Usually Indirect fall on Abducted and
extended shoulder
• May be direct when there is a blow on the
shoulder from behind

278. Anterior Dislocation

279. Anterior Dislocation

280. Posterior dislocation
AP
Scapular ‘Y’ view
Axillary view

281. Luxatio erecta

282. Acromioclavicular Joint
• The AC joint is different from joints like the
knee or ankle, because it doesn't need to
move very much. The AC joint only needs to
be flexible enough for the shoulder to move
freely. The AC joint just shifts a bit as the
shoulder moves.

283. • The
AcromioClavicular
joint is stabilized
by three
ligaments
– 2 CC ligaments
• Conoid
• trapezoid
– AC ligament

284. Acromioclavicular separation
Mechanisms of Injury:
• Fall on the tip of the unprotected shoulder.
• Fall on the outstretched hand.
• Downward force on the acromion from above.

285. Acromioclavicular separation
• Rockwood Classification:
– type I: sprain of joint with out a complete tear of either
ligament
– type II: tear of AC ligaments with intact coracoclavicular
ligaments; will not show marked elevation of lateral end of
clavicle
–type III: both AC & CC ligaments are torn
– type IV: distal clavicle is dislocated posteriorly into
trapezial fascia
– type V: distal clavicle is dislocated inferiorly

286. Grades of Shoulder Separation

288. Shoulder Fractures

289. Greater tuberosity fracture
Longitudinal ultrasound
scan of the supraspinatus
tendon demonstrates
contour irregularity
compatible with fracture
Corresponding T2-
weighted MR arthrogram
confirms the greater
tuberosity fracture

290. Tumors
• Proximal humerus –
– Simple bone cyst
– Aneurysmal bone cyst
– Giant Cell Tumor of Bone
– Osteosarcoma (common)
– Enchondroma (relatively common)
– Periosteal chondroma (just proximal to insertion of deltoid)
– Osteochondroma
– Chondroblastoma
– Chondromyxoid fibroma
– Metastases
• Scapula –
– Osteochondroma
– chondrosarcoma: affects the shoulder girdle

291. Role of interventional radiology
• US and fluoroscopy guided intra-articular and
bursal infiltration (steroids, other drugs)
• Percutaneous needle removal of calcific deposits
• Capsular distension/infiltration of adhesive
capsulitis
• Therapeutic aspiration of suprascapular or
spinoglenoid cysts (to relieve suprascapular nerve
compression)
• Percutaneous radio-frequency treatment of
symptomatic bone metastases under CT guidance

292. Conclusion
•Plain radiographs are useful as an initial screening test with
patients with shoulder pain.
•Ultrasound may be used for diagnosing rotator cuff disease
(> 90 % sensitive and specific for tears).
•CT useful only in cases of trauma and to detect associated
bony abnormalities
•MRI is the ‘modality of choice’ for most of the shoulder
pathologies.
•MR arthrography or CT arthrography is required for
investigating instability

293. Thank you…….