1、SHOULDER INSTABILITY AND ROTATOR CUFF INJURIES,J.GARCIA,INTRODUCTION,Shoulder injuries comprise 8-13% of all athletes injuries Result from . repetitive overload activities:swimming,tennis . or direct trauma(collision) :football,rugby,INCIDENCE,SPORTS % TYPE OF LESIONS Baseball 11-17 AC , imping.,RC
2、tenditis Wrestling 17 Glenohum sublux or dislocation,AC Tennis 56 RC tendinitis,imping. Volley-ball 44 Biceps tendinitis,imping. Javelin throwers 29 Biceps tendinitis,imping. etc,SHOULDER ANATOMY,Bones : humeral head and glenoid Cartilage and labrum Capsule and ligaments Muscles,BELTRAN,PLASTICITY O
3、F LABRUM,Articular cartilage, and glenoid labrum.Labrum which have some plasticity seen on different positions,External rotation of humerus Internal rotation,ANTERIOR CAPSULE INSERTION,Type III ,the more medial insertion ,is prone to anterior glenohumeral instability From BELTRAN Imaging of orthoped
4、ic sports injuries SPRINGER 2007,p 129,3 types of insertion,SHOULDER BIOMECHANICS,Shoulder is the most mobile joint in the human body Function requires coordinated motion of 4 joints . scapuloclavicular . acromioclavicular . glenohumeral . scapulothoracic,SHOULDER BIOMECHANICS,Motion 0-180% in eleva
5、tion internal and external rotation 150% anterior and posterior rotation 170%,STABILIZING MECHANISMS OF GLENOHUMERAL JOINT,PASSIVE MECHANISMS .Size,shape,tilt ot the glenoid fossa .Negative intracapsular pressure .Adhesion,cohesion of articular surfaces .Ligaments and capsule .Glenoid labrum .Oseous
6、 bone restraints :acromion,coracoid process,STABILIZING MECHANISMS OF GLENOHUMERAL JOINT,ACTIVE STABILIZING MECHANISMS . long head of the biceps tendon . rotator cuff muscles . subscapularis muscle,Coronal Sagittal,Axial ArthroMR,“VICIOUS CIRCLE“ OF SHOULDER INJURIES,Pain occurs in women especially
7、when there is a physiologic instability that may be multidirectional STONE 1994,INSTABILITY,COMPRESSION IMPINGEMENT,PAIN MUSCULAR IMBALANCE,ROTATOR CUFF WEAKNESS,LAXITY vs INSTABILITY Definitions,LAXITY : the ability to passively translate humeral head to the glenoid fossa INSTABILITY : a clinicalco
8、ndition in which symptoms are produced by the unwanted translation of the umeral head ,giving rise to pain or diminished shoulder function,SHOULDER INSTABILITY,This lecture is mainly devoted to gleno-humeral instability due to time limitations ,but DO NOT FORGET please scapular,clavicular ,acromio-c
9、lavicular, sternoclavicular injuries which are also seen in sports activities,THE OVERHEAD N THROWING MECHANISM,Center of rotation The curved harrow represents the path and direction of the greater tuberosity a sthe arm externally rotates BELTRAN 2007,IMAGING TECHNIQUES,RADIOGRAPHY AP,axial views CT
10、, ARTHRO-CT MRI, ARTHRO-MR,RADIOGRAPHY,Antero-inferior dislocation on AP and Neer views. Axial view is better than Neer to appreciate correctly the humeral head position,Axial view,ARTHRO-CT,Arthro-CT for staging of lesions after bilateral gleno-humeral dislocation : humeral head bone defects and gl
11、enoid lesions,ARTHRO-MR,Arthro-MR technique :iodine contrast and diluted Gd.Radiography after fluoscopic guidance and MR (3 planes,T1 w FS and T2w),ANTERIOR INSTABILITY,More frequent 90% Recurrences 50% In young patients,after trauma,ABNORMALITIES IN ANTERIOR INSTABILITY,Avulsion of gelnoid labrum 7
12、5% IGH ligament lesion,HILL-SACHS 50% SLAP lesions 25% Capsule laxity Rotator cuff teras (older patients) 20%,ANTERO-INFERIOR DISLOCATION,First episode Third recurrence,BONE LESIONS AFTER ANTERO-INFERIOR DISLOCATION,Dislocation After reduction ,Hill Sachs lesion,ASSOCIATION OF LESIONS,Bankart lesion
13、 type 4 Hill Sachs lesion (same patient),BANKART LESIONS,Arthro-MR :Bankart type III,4 types of Bankart to,1:small,3 severe,4 fracture,ASSOCIATION OF LESIONS,Avulsion,fracture and loose body From BELTRAN,Radiographics 1994,666,POSTERIOR INSTABILITY,Less common 5% Unidirectional is uncommon.Commonly
14、bidirectional (post and inf ) or multidirectional In epilepsy,ethanol,elcetricity shock ( 3 E rule) Also during repetitive applied athletic forces: swimming,throwing,punching,and in sports collision such as football,POSTERIOR INSTABILITY,Clinical diagnosis much more difficult than in anterior instab
15、ility Imaging techniques are important Especially the first radiographic evaluation is ESSENTIAL,POSTERIOR INSTABILITY,Posterior dislocation with fracture of anterior aspect of the humeral head(inverse of Hill.Sachs injury),POSTERIOR INSTABILITY,Posterior dislocation with “poterior Bankart“ From TIR
16、MAN ,MRI clinics N Am 1997,883,MICROINSTABILITY OF SHOULDER,Microinstability concerns the 1/3 sup joint in sportmen and sportwomen ,especially for risk of SLAP lesions Arthro-MR is superior to native MR for a good staging of lesions,including views in ABER position,MR in ABER POSITION,For anterior s
17、houlder instability For capsule and labrum injuries For HILL SACHS injuries,WINTZELL 1998,MULTIDIRECTIONAL INSTABILITY,Instability more than in one direction Antero-inferior,postero-inferior,or 3 directions Often atraumatic(without trauma) ,or violent injury,or repeated microtrauma,ISOLATED LABRUM T
18、EARS,Tears without instability But source of dysfunction In the athletic population Injury similar to gleno-humeral dislocation Sensation of instability,LABRUM TEARS,SLAP lesion type 2 c ,on arthro-MR SLAP= S superior L labrum A anterior P posterior,ARTHRO-MR IS THE TECHNIQUE OF CHOICE,ROTATOR CUFF
19、INJURIES,Age is important in shoulder pathology According to Hoffmeyer 30 y. tendinopathies,tears 40 y. tears,perforation 50 y. gleno-humeral osteoarthritis (OA) Med.Hyg 1998,56:2218,IMPINGEMENT SYNDROME,95% of rotator cuff(RC) lesions,Neer 1972 Mechanical injury from compression of the subacromial
20、structures :Suprasupinatus (SSP) tendon,greater tuberosity of humerus, subacromial bursa,SECONDARY IMPINGEMENT,In young patients and athletes involved in throwing sports, shoulder impingement can occur with instability,IMAGING TECHNIQUES,RADIOGRAPHY SONOGRAPHY MRI AND ARTHRO-MR,RADIOGRAPHY,AP ,neutr
21、al rotation,Internal rotation External rotation,Neer view,At least AP neutral and Neer views, sometimes int. et ext. rotation!,SONOGRAPHY,Technique . broadband-transducers 5-12 MHz . different types of probe,including type“hockey-stick-shaped“ Multidirectional approach Dynamic and comparative study
22、( both sides) Only perpendicular structures,because obliquity creates artefacts Operator dependant,SONOGRAPHY,ESSENTIAL REQUIREMENTS: .personnal experience .rigourous examination .very good knowledge of anatomy,Position of probe for anterior approach of sholuder,SONOGRAPHY FINDINGS,Degenerative supr
23、asupinatus tendon and tear,Posttraumatic SSP tear,SIGNS OF RC TEARS,DIRECT SIGNS OF COMPLETE TEAR 1.Flat area,scale of the border 2.Anechoic zone through the tendon 3.Massive thiness of the tendon 4.Tendon invisible INDIRECT SIGNS 1.Erosions of the greater tuberosity 2. Subacromial bursitis,joint fl
24、uid 3. Deltoid herniation 4. Muscle atrophy PEETRONS 2000,SONOGRAPHY,EFFICIENCY IN PARTIAL RC TEARS Sensitivity 93 % Specificity 94% HOLSBEECK Mv Radiology 1995,197:443 BUT ONLY BY EXPERIENCED OPERATOR !,MAGNETIC RESONANCE,MR offers a multiplanar approach and a good tissue differenciation (the best)
25、 Examination in 3 planes:coronal,sagittal,axial Multiple sequences :PD for anatomy T2 w FS for signal FE 3 D for cartilage Arthro-MR for incomplete tears,labrum tears,MAGNETIC RESONANCE,Coronal,Axial,Sagittal,ANATOMIC VARIATIONS THAT MAY PREDISPOSE TO IMPINGEMENT,Acromial shape Acromial lateral tilt
26、 Diminished arch eight Coracoid lenght Muscle hypertrophy Os acromiale Displaced greater tuberosity,Acromial shape flat,curved, hocked,ACROMIAL SHAPE AND RC TEARS,Hocked acromion on AP and NEER views,Atrhro-MR T1 FS :complete tear of SSP tendon,ROTATOR CUFF TEARS,Functional infirmity Elevation of R
27、upper limb impossible Arthro-MR :complete tear of SSP tendon wit retraction,ROTATOR CUFF TEARS,Dimensions of full thickness tears classified on basis of greatest dimensions Small 5 cm De Orio ,Cofield JBJS am 1984 ,66(4):563,PARTIAL RC TEARS,Inferior SSP tear more common than superior tear Not treat
28、ed may lead to chronic pain and invalidity May propagate to full thickness tear Grading of partial tears 1. less 3 mm 2. 3-6 mm 3. more 6 mm,PARTIAL RC TEARS,Arthro-MR : inferior partial of the suprasupinatus tendon;no perforation,no passage of contrast medium in subacromial bursa,MULTIPLE RC TEARS,
29、Sometimes infrasupinatus and subscapularis tears are associated with a suprasupinatus tear A complete good staging is compulsory for choosing the best tt ,especially before eventual surgery (which type of surgical repair) For a such evaluation, MR and sometimes arthroMR , are the techniques of choic
30、e,MULTIPLE RC TEARS,Suprasupinatus complete tear,retraction of tendon,muscle atrophy with infrasupinatus partial tear and muscle atrophy .Also OA in AC,EXTENT OF RC TEARS,THOMAZEAU Clin Orthop Relat Res 1997,344:275,MUSCLE ATROPHY,Muscle atrophy follows a rotator cuff tear not treated Muscle atrophy
31、 very well appreciated by MR Depends on the lenght of evolution Stage 1. few fatty trails 2. more muscle than fat 3. muscle=fat 4. more fat than muscle After 6 months of evolution stage 2,after 1 year stage 4 Goutalier D Clin Orthop 1994,304:78,MUSCLE ATROPHY,A normal SSP muscle occupy the whole sup
32、raspinatus area When atrophy the volume decreased,ACROMIOCLAVICULAR JOINT INJURIES,Very often in looking for an eventual RC tear ,an acromioclavicular joint injury is discovered,such as osteoarthritis with bony spurs ,and even with an inflammatory component(bone marrow edema , joint fluid, and somet
33、imes a subacromial bursitis),ACROMIOCLAVICULAR JOINT INJURIES,PD T2w FS Osteoarthritis of the acromioclavicular joint with inflammatory signs and RC impingement,BICEPS TENDON INJURIES,The long tendon of the biceps had an extraarticular portion in the bicipital groove and an intraarticular portion,BI
34、CEPS TENDON INJURIES,Injuries of the long tendon of the biceps may mimic a RC impingement Biceps tendon injuries : . tendinopathy . partial thickness tear . complete disruption . dislocation of the extra-articular portion,BICEPS TENDON INJURIES,Possibility of tendon tear Tendinitis:enlargement,incre
35、ased signal into the tendon,CONCLUSIONS,Shoulder instability and rotator cuff injuries are common in certain sport activities Even a good clinician can not always make a correct and complete diagnosis Therefore imaging techniques have a great role in giving precise informations, concerning the different contributing factors, and allows to choose the best treatement and to precise the procedure when a surgical treatement is on discussion,
