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Rotator Cuff Tears: Clinical, Radiographic, and US Findings¹

¹ From the Department of Radiology, North Shore University Hospital, 825 Northern Blvd, Great Neck, NY 11021. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received November 16, 2004; revision requested January 4, 2005, and received January 28; accepted January 31. All authors have no financial relationships to disclose.

View larger version (151K): [in a new window]   Figure 1.  Clinical photograph illustrates evaluation for supraspinatus muscle weakness. With the elbow straight and the arm in 20° abduction, the patient is asked to abduct the arm (arrow) against an applied resistance.

 

View larger version (51K): [in a new window]   Figure 2a.  Clinical photographs illustrate evaluation for impingement. (a) The examiner fully elevates the patient’s arm (to at least 170°). (b) Next, the patient’s humerus is internally rotated (arrow) and adducted against the ear. Afterward, the humerus is externally rotated and adducted against the ear (not shown). If there is increased pain with rotation in either direction, the test is positive.

 

View larger version (64K): [in a new window]   Figure 2b.  Clinical photographs illustrate evaluation for impingement. (a) The examiner fully elevates the patient’s arm (to at least 170°). (b) Next, the patient’s humerus is internally rotated (arrow) and adducted against the ear. Afterward, the humerus is externally rotated and adducted against the ear (not shown). If there is increased pain with rotation in either direction, the test is positive.

 

View larger version (162K): [in a new window]   Figure 3.  Clinical photograph illustrates evaluation for external rotation weakness. The patient’s elbow is flexed 90°, and the shoulder is internally rotated 20°. The examiner then places his or her hand outside the patient’s wrist and asks the patient to resist (arrow) an inward force.

 

View larger version (152K): [in a new window]   Figure 4.  Clinical photograph illustrates evaluation for subscapularis tear. The patient’s arm is passively positioned behind the back with the palm facing outward. The patient is then asked to lift the hand away from the back or push off against resistance.

 

View larger version (100K): [in a new window]   Figure 5.  Radiograph (supraspinatus outlet view) shows the normal supraspinatus muscle, which has a homogeneous appearance with a bulging superior contour (solid arrows). Note also the type III acromion (open arrow).

 

View larger version (151K): [in a new window]   Figure 6.  Chronic rotator cuff tear. Anteroposterior radiograph demonstrates a high-riding humerus with decreased acromiohumeral distance (black arrows). Secondary cuff arthropathy is also seen, manifesting as faceting and sclerosis in the inferolateral aspect of the acromion and the superior aspect of the greater tuberosity (*). Note also the osteophytosis arising from the humerus (white arrow).

 

View larger version (111K): [in a new window]   Figure 7.  Clinical photograph illustrates patient positioning for US evaluation of the long head of the biceps tendon. The forearm is supinated and placed on the thigh, bringing the bicipital groove (black line) forward.

 

View larger version (115K): [in a new window]   Figure 8a.  Transverse view of the long head of the biceps tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the longitudinal course of the tendon (dashed line). Solid line indicates the clavicle. (b) US image shows the biceps tendon (arrows) in the bicipital groove between the greater (G) and lesser (L) tuberosities. (c) US image obtained with the ultrasound beam not perpendicular to the tendon (arrows) demonstrates anisotropy, in which the tendon appears artifactually hypoechoic to anechoic.

 

View larger version (120K): [in a new window]   Figure 8b.  Transverse view of the long head of the biceps tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the longitudinal course of the tendon (dashed line). Solid line indicates the clavicle. (b) US image shows the biceps tendon (arrows) in the bicipital groove between the greater (G) and lesser (L) tuberosities. (c) US image obtained with the ultrasound beam not perpendicular to the tendon (arrows) demonstrates anisotropy, in which the tendon appears artifactually hypoechoic to anechoic.

 

View larger version (115K): [in a new window]   Figure 8c.  Transverse view of the long head of the biceps tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the longitudinal course of the tendon (dashed line). Solid line indicates the clavicle. (b) US image shows the biceps tendon (arrows) in the bicipital groove between the greater (G) and lesser (L) tuberosities. (c) US image obtained with the ultrasound beam not perpendicular to the tendon (arrows) demonstrates anisotropy, in which the tendon appears artifactually hypoechoic to anechoic.

 

View larger version (110K): [in a new window]   Figure 9a.  Longitudinal view of the long head of the biceps tendon. (a) Clinical photograph illustrates the US transducer oriented longitudinal to the tendon. Black line indicates the clavicle. (b) On a US image, the biceps tendon (arrows) manifests as echogenic fibrillar lines interposed between the deltoid muscle (D) and the humerus (H).

 

View larger version (102K): [in a new window]   Figure 9b.  Longitudinal view of the long head of the biceps tendon. (a) Clinical photograph illustrates the US transducer oriented longitudinal to the tendon. Black line indicates the clavicle. (b) On a US image, the biceps tendon (arrows) manifests as echogenic fibrillar lines interposed between the deltoid muscle (D) and the humerus (H).

 

View larger version (128K): [in a new window]   Figure 10.  Clinical photograph illustrates patient positioning for US evaluation of the subscapularis tendon. The arm is externally rotated, bringing the tendon (black box) into a more anterior position.

 

View larger version (113K): [in a new window]   Figure 11a.  Longitudinal view of the subscapularis tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the arm but longitudinal to the subscapularis tendon (shaded box). (b, c) On US images, the subscapularis tendon (small arrows in b, arrows in c) is seen at its insertion site on the lesser tuberosity (L) and extending to the bicipital groove (B). By externally rotating the humerus in the direction indicated by the large arrow in b, more of the tendon is brought into view (cf c). (d) Corresponding axial proton-density–weighted MR image also shows the subscapularis tendon (arrows). The box corresponds to the field of view in the US images.

 

View larger version (133K): [in a new window]   Figure 11b.  Longitudinal view of the subscapularis tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the arm but longitudinal to the subscapularis tendon (shaded box). (b, c) On US images, the subscapularis tendon (small arrows in b, arrows in c) is seen at its insertion site on the lesser tuberosity (L) and extending to the bicipital groove (B). By externally rotating the humerus in the direction indicated by the large arrow in b, more of the tendon is brought into view (cf c). (d) Corresponding axial proton-density–weighted MR image also shows the subscapularis tendon (arrows). The box corresponds to the field of view in the US images.

 

View larger version (115K): [in a new window]   Figure 11c.  Longitudinal view of the subscapularis tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the arm but longitudinal to the subscapularis tendon (shaded box). (b, c) On US images, the subscapularis tendon (small arrows in b, arrows in c) is seen at its insertion site on the lesser tuberosity (L) and extending to the bicipital groove (B). By externally rotating the humerus in the direction indicated by the large arrow in b, more of the tendon is brought into view (cf c). (d) Corresponding axial proton-density–weighted MR image also shows the subscapularis tendon (arrows). The box corresponds to the field of view in the US images.

 

View larger version (152K): [in a new window]   Figure 11d.  Longitudinal view of the subscapularis tendon. (a) Clinical photograph illustrates the US transducer oriented transverse to the arm but longitudinal to the subscapularis tendon (shaded box). (b, c) On US images, the subscapularis tendon (small arrows in b, arrows in c) is seen at its insertion site on the lesser tuberosity (L) and extending to the bicipital groove (B). By externally rotating the humerus in the direction indicated by the large arrow in b, more of the tendon is brought into view (cf c). (d) Corresponding axial proton-density–weighted MR image also shows the subscapularis tendon (arrows). The box corresponds to the field of view in the US images.

 

View larger version (135K): [in a new window]   Figure 12a.  Transverse view of the subscapularis tendon. US image (a) and corresponding sagittal oblique fat-suppressed T2-weighted MR image (b) show the subscapularis tendon (arrows in b). Note the echogenic tendon slips (arrows in a). The box in b corresponds to the field of view in a.

 

View larger version (180K): [in a new window]   Figure 12b.  Transverse view of the subscapularis tendon. US image (a) and corresponding sagittal oblique fat-suppressed T2-weighted MR image (b) show the subscapularis tendon (arrows in b). Note the echogenic tendon slips (arrows in a). The box in b corresponds to the field of view in a.

 

View larger version (184K): [in a new window]   Figure 13.  Clinical photograph illustrates patient positioning for US evaluation of the supraspinatus tendon. The hand is placed on the buttock with the elbow pointed backward, bringing the insertion site (i) of the supraspinatus tendon (shaded box) on the superior aspect of the greater tuberosity out from beneath the acromion and into view.

 

View larger version (120K): [in a new window]   Figure 14a.  Longitudinal view of the supraspinatus tendon. (a) Clinical photograph illustrates the US transducer placed anterior to the acromioclavicular joint and roughly parallel to the spine of the scapula (black line on top of shoulder) for longitudinal evaluation of the supraspinatus tendon (shaded box). Black line on front of shoulder indicates the clavicle. (b, c) US image (b) and corresponding coronal oblique proton-density–weighted MR image (c) demonstrate the supraspinatus tendon (arrows). The box in c corresponds to the field of view in b.

 

View larger version (112K): [in a new window]   Figure 14b.  Longitudinal view of the supraspinatus tendon. (a) Clinical photograph illustrates the US transducer placed anterior to the acromioclavicular joint and roughly parallel to the spine of the scapula (black line on top of shoulder) for longitudinal evaluation of the supraspinatus tendon (shaded box). Black line on front of shoulder indicates the clavicle. (b, c) US image (b) and corresponding coronal oblique proton-density–weighted MR image (c) demonstrate the supraspinatus tendon (arrows). The box in c corresponds to the field of view in b.

 

View larger version (169K): [in a new window]   Figure 14c.  Longitudinal view of the supraspinatus tendon. (a) Clinical photograph illustrates the US transducer placed anterior to the acromioclavicular joint and roughly parallel to the spine of the scapula (black line on top of shoulder) for longitudinal evaluation of the supraspinatus tendon (shaded box). Black line on front of shoulder indicates the clavicle. (b, c) US image (b) and corresponding coronal oblique proton-density–weighted MR image (c) demonstrate the supraspinatus tendon (arrows). The box in c corresponds to the field of view in b.

 

View larger version (113K): [in a new window]   Figure 15a.  Transverse view of the supraspinatus tendon. (a) Photograph shows transducer position for transverse evaluation of the supraspinatus tendon (box). The transducer is turned 90° (cf Fig 14a). Black lines indicate the spine of the scapula and the clavicle. (b) Transverse US image of the shoulder shows the deltoid muscle, peribursal fat (arrowheads) surrounding the subacromial subdeltoid bursa (small arrows), the supraspinatus tendon, and the cartilage (c) and underlying cortex of the humerus (large arrows). (c) US image shows how moving the transducer more anteriorly and inferiorly around the humeral head curvature brings the round hyperechoic biceps tendon (dashed oval) into view. About 2.0–2.5 cm of tendon posterior to the biceps tendon is the supraspinatus tendon (cursors), with the infraspinatus tendon more posterior. (d) Sagittal oblique fat-suppressed proton-density–weighted MR image shows the supraspinatus tendon in the transverse plane (arrows). Box corresponds to field of view in b.

 

View larger version (149K): [in a new window]   Figure 15b.  Transverse view of the supraspinatus tendon. (a) Photograph shows transducer position for transverse evaluation of the supraspinatus tendon (box). The transducer is turned 90° (cf Fig 14a). Black lines indicate the spine of the scapula and the clavicle. (b) Transverse US image of the shoulder shows the deltoid muscle, peribursal fat (arrowheads) surrounding the subacromial subdeltoid bursa (small arrows), the supraspinatus tendon, and the cartilage (c) and underlying cortex of the humerus (large arrows). (c) US image shows how moving the transducer more anteriorly and inferiorly around the humeral head curvature brings the round hyperechoic biceps tendon (dashed oval) into view. About 2.0–2.5 cm of tendon posterior to the biceps tendon is the supraspinatus tendon (cursors), with the infraspinatus tendon more posterior. (d) Sagittal oblique fat-suppressed proton-density–weighted MR image shows the supraspinatus tendon in the transverse plane (arrows). Box corresponds to field of view in b.

 

View larger version (131K): [in a new window]   Figure 15c.  Transverse view of the supraspinatus tendon. (a) Photograph shows transducer position for transverse evaluation of the supraspinatus tendon (box). The transducer is turned 90° (cf Fig 14a). Black lines indicate the spine of the scapula and the clavicle. (b) Transverse US image of the shoulder shows the deltoid muscle, peribursal fat (arrowheads) surrounding the subacromial subdeltoid bursa (small arrows), the supraspinatus tendon, and the cartilage (c) and underlying cortex of the humerus (large arrows). (c) US image shows how moving the transducer more anteriorly and inferiorly around the humeral head curvature brings the round hyperechoic biceps tendon (dashed oval) into view. About 2.0–2.5 cm of tendon posterior to the biceps tendon is the supraspinatus tendon (cursors), with the infraspinatus tendon more posterior. (d) Sagittal oblique fat-suppressed proton-density–weighted MR image shows the supraspinatus tendon in the transverse plane (arrows). Box corresponds to field of view in b.

 

View larger version (152K): [in a new window]   Figure 15d.  Transverse view of the supraspinatus tendon. (a) Photograph shows transducer position for transverse evaluation of the supraspinatus tendon (box). The transducer is turned 90° (cf Fig 14a). Black lines indicate the spine of the scapula and the clavicle. (b) Transverse US image of the shoulder shows the deltoid muscle, peribursal fat (arrowheads) surrounding the subacromial subdeltoid bursa (small arrows), the supraspinatus tendon, and the cartilage (c) and underlying cortex of the humerus (large arrows). (c) US image shows how moving the transducer more anteriorly and inferiorly around the humeral head curvature brings the round hyperechoic biceps tendon (dashed oval) into view. About 2.0–2.5 cm of tendon posterior to the biceps tendon is the supraspinatus tendon (cursors), with the infraspinatus tendon more posterior. (d) Sagittal oblique fat-suppressed proton-density–weighted MR image shows the supraspinatus tendon in the transverse plane (arrows). Box corresponds to field of view in b.

 

View larger version (123K): [in a new window]   Figure 16a.  Longitudinal view of the supraspinatus muscle. (a) Clinical photograph illustrates the transducer placed in the supraspinatus fossa, anterior and parallel to the spine of the scapula (black line). (b) US image shows the supraspinatus muscle (arrows) interposed between the trapezius muscle and the scapula.

 

View larger version (153K): [in a new window]   Figure 16b.  Longitudinal view of the supraspinatus muscle. (a) Clinical photograph illustrates the transducer placed in the supraspinatus fossa, anterior and parallel to the spine of the scapula (black line). (b) US image shows the supraspinatus muscle (arrows) interposed between the trapezius muscle and the scapula.

 

View larger version (142K): [in a new window]   Figure 17a.  Evaluation of the posterior aspect of the shoulder. (a) Clinical photograph illustrates the US transducer position. (b, c) US image (b) and axial gradient-echo MR image (c) show the posterior aspect of the glenohumeral joint. The normal posterior labrum (arrows) is homogeneously hyperechoic at US and hypointense at MR imaging. The box in c corresponds to the field of view in b.

 

View larger version (104K): [in a new window]   Figure 17b.  Evaluation of the posterior aspect of the shoulder. (a) Clinical photograph illustrates the US transducer position. (b, c) US image (b) and axial gradient-echo MR image (c) show the posterior aspect of the glenohumeral joint. The normal posterior labrum (arrows) is homogeneously hyperechoic at US and hypointense at MR imaging. The box in c corresponds to the field of view in b.

 

View larger version (169K): [in a new window]   Figure 17c.  Evaluation of the posterior aspect of the shoulder. (a) Clinical photograph illustrates the US transducer position. (b, c) US image (b) and axial gradient-echo MR image (c) show the posterior aspect of the glenohumeral joint. The normal posterior labrum (arrows) is homogeneously hyperechoic at US and hypointense at MR imaging. The box in c corresponds to the field of view in b.

 

View larger version (139K): [in a new window]   Figure 18a.  Full-thickness tear of the supraspinatus tendon. (a) Longitudinal US image demonstrates a full-thickness hypoechoic defect in the normal location of the supraspinatus tendon (arrows). This defect represents fluid and extends from the bursal surface to the articular surface. Note the torn edge of the retracted supraspinatus tendon (S). (b) Transverse US image shows an intact infraspinatus tendon (i) posterior to the tear. The double cortex sign can also be seen; the overlying fluid accentuates the appearance of the cartilage (arrows), which is almost as hyperechoic as the underlying cortex. (c) Corresponding coronal oblique fat-suppressed T2-weighted MR image shows the full-thickness defect (arrows) and the torn retracted edge of the supraspinatus tendon (S). The box corresponds to the field of view in a.

 

View larger version (149K): [in a new window]   Figure 18b.  Full-thickness tear of the supraspinatus tendon. (a) Longitudinal US image demonstrates a full-thickness hypoechoic defect in the normal location of the supraspinatus tendon (arrows). This defect represents fluid and extends from the bursal surface to the articular surface. Note the torn edge of the retracted supraspinatus tendon (S). (b) Transverse US image shows an intact infraspinatus tendon (i) posterior to the tear. The double cortex sign can also be seen; the overlying fluid accentuates the appearance of the cartilage (arrows), which is almost as hyperechoic as the underlying cortex. (c) Corresponding coronal oblique fat-suppressed T2-weighted MR image shows the full-thickness defect (arrows) and the torn retracted edge of the supraspinatus tendon (S). The box corresponds to the field of view in a.

 

View larger version (180K): [in a new window]   Figure 18c.  Full-thickness tear of the supraspinatus tendon. (a) Longitudinal US image demonstrates a full-thickness hypoechoic defect in the normal location of the supraspinatus tendon (arrows). This defect represents fluid and extends from the bursal surface to the articular surface. Note the torn edge of the retracted supraspinatus tendon (S). (b) Transverse US image shows an intact infraspinatus tendon (i) posterior to the tear. The double cortex sign can also be seen; the overlying fluid accentuates the appearance of the cartilage (arrows), which is almost as hyperechoic as the underlying cortex. (c) Corresponding coronal oblique fat-suppressed T2-weighted MR image shows the full-thickness defect (arrows) and the torn retracted edge of the supraspinatus tendon (S). The box corresponds to the field of view in a.

 

View larger version (153K): [in a new window]   Figure 19.  Sagging peribursal fat sign. Longitudinal US image shows a mildly retracted tear of the supraspinatus tendon (S), with sagging of the overlying hyperechoic peribursal fat (arrows).

 

View larger version (150K): [in a new window]   Figure 20a.  Shoulder joint effusion tracking into the biceps tendon sheath. Transverse US image (a) and axial gradient-echo MR image (b) demonstrate an effusion in the biceps tendon sheath (arrows). The box in b corresponds to the field of view in a.

 

View larger version (148K): [in a new window]   Figure 20b.  Shoulder joint effusion tracking into the biceps tendon sheath. Transverse US image (a) and axial gradient-echo MR image (b) demonstrate an effusion in the biceps tendon sheath (arrows). The box in b corresponds to the field of view in a.

 

View larger version (144K): [in a new window]   Figure 21a.  Partial-thickness tear of the supraspinatus tendon. Longitudinal US image (a) and coronal oblique fat-suppressed T2-weighted MR image (b) show a focal, well-defined defect in the supraspinatus tendon (arrow in a) extending to the articular surface with cortical irregularity and a small subacromial effusion. The box in b corresponds to the field of view in a.

 

View larger version (133K): [in a new window]   Figure 21b.  Partial-thickness tear of the supraspinatus tendon. Longitudinal US image (a) and coronal oblique fat-suppressed T2-weighted MR image (b) show a focal, well-defined defect in the supraspinatus tendon (arrow in a) extending to the articular surface with cortical irregularity and a small subacromial effusion. The box in b corresponds to the field of view in a.

 

View larger version (174K): [in a new window]   Figure 22a.  Subscapularis tendon tear with subluxation of the long head of the biceps tendon. Transverse US image (a) and axial proton-density–weighted MR image (b) show a tear of the subscapularis tendon (arrow), with the biceps tendon (b) perched on the lesser tuberosity (L).

 

View larger version (179K): [in a new window]   Figure 22b.  Subscapularis tendon tear with subluxation of the long head of the biceps tendon. Transverse US image (a) and axial proton-density–weighted MR image (b) show a tear of the subscapularis tendon (arrow), with the biceps tendon (b) perched on the lesser tuberosity (L).

 

View larger version (136K): [in a new window]   Figure 23.  Tendinosis. On a longitudinal US image, the supraspinatus tendon (arrows) is thickened and heterogeneous with no discrete defects. Instead, an ill-defined hypoechoic defect with indistinct borders is seen (*).

 

View larger version (116K): [in a new window]   Figure 24a.  Calcific tendinitis. (a) Radiograph demonstrates deposition of calcium hydroxyapatite (arrow) just superior to the greater tuberosity at the insertion site of the supraspinatus tendon. (b) US image shows calcium deposition within the supraspinatus tendon as a lobular echogenic area without shadowing (arrows). Note also the effusion in the subdeltoid bursa (*).

 

View larger version (117K): [in a new window]   Figure 24b.  Calcific tendinitis. (a) Radiograph demonstrates deposition of calcium hydroxyapatite (arrow) just superior to the greater tuberosity at the insertion site of the supraspinatus tendon. (b) US image shows calcium deposition within the supraspinatus tendon as a lobular echogenic area without shadowing (arrows). Note also the effusion in the subdeltoid bursa (*).

 

View larger version (140K): [in a new window]   Figure 25.  Subdeltoid bursitis. Longitudinal US image of the biceps tendon demonstrates a fluid collection (arrows) superficial to and not involving the biceps tendon (b).

 

View larger version (135K): [in a new window]   Figure 26a.  Fracture. Longitudinal US image (a) and corresponding coronal oblique fat-suppressed T2-weighted MR image (b) demonstrate an intact supraspinatus tendon (small arrows in a) and a cortical break in the humeral head (large arrow in a, arrow in b). Adjacent high-signal-intensity bone marrow edema is evident on the MR image (*). The box in b corresponds to the field of view in a.

 

View larger version (129K): [in a new window]   Figure 26b.  Fracture. Longitudinal US image (a) and corresponding coronal oblique fat-suppressed T2-weighted MR image (b) demonstrate an intact supraspinatus tendon (small arrows in a) and a cortical break in the humeral head (large arrow in a, arrow in b). Adjacent high-signal-intensity bone marrow edema is evident on the MR image (*). The box in b corresponds to the field of view in a.

 

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