Dr. Patrick Denard walks through reading shoulder MRI for rotator cuff tears, starting with clinical symptoms and moving through axial, coronal, and sagittal views. He spots a biceps tear and upper subscapularis tear often missed, a large retracted supraspinatus tear, and fatty infiltration that made him augment the repair instead of a standard fix.
Hi, I'm Dr. Patrick Denard. I'm an orthopedic surgeon who specializes in the shoulder, which means 100% of my practice is dedicated to understanding and helping patients solve shoulder problems. So I'm going to show you in this video how I approach evaluating a rotator cuff tear on MRI. Now I first of course begin by understanding symptoms and the physical examination, but once I go to the MRI, I want to understand the tear pattern and the repair options that we might have if surgery is what is chosen. So I begin by looking at the axillary sequence. Now, the axillary sequence is when somebody's lying down, we're gonna go top to bottom. So here we're looking at the humeral head or ball on the right side and then on the glenoid on the left side. So here's the humeral head and the glenoid. We see a little bit of arthritis or cystic change in this case on the glenoid. But here I wanna point out the biceps tendon and we're gonna track the biceps tendon up and down. And it's important to do that because as we track up and down, it's often that radiologists and surgeons miss tears, especially of the upper subscapularis tendon. Now, the subscapularis is the largest rotator cuff muscle that's in the front of your shoulder. It helps elevate the arm and turn in. And again, it's really common that these tears are missed. In fact, studies we've done have suggested that radiologists miss these tears in 50% of cases. So here, as I look at the upper aspect of the subscapularis tendon, I see two things. One is I see the biceps starting to cut into the joint Secondly, I see a white signal here. Now the normal tendon is black as it comes all the way over to the insertion of the bone. In this case, we see some white signal showing a tear of the upper subscapularis tendon in this particular individual. So now we know so far we have some tearing of the biceps tendon as well as tearing of the upper subscapularis. Next, I'll move on to what's called the coronal view. This is looking at the patient or individual straight on from front to back as if they're standing up. Here we're going to evaluate the supraspinatus and infraspinatus. We have the humeral head again on the right, or the ball on the right, and the glenoid or socket on the left. Again, we do see a little bit of arthritis in this case. It's not so much that it needs a shoulder replacement in this particular case, but we do see that there's some arthritis. Now in this sequence, we see that muscle is in gray and tendon is in black. So here's the supraspinatus in gray on top, and then we see the tendon on after that in black. Now the black tendon here should be all the way out to the edge. So this edge here should be all the way over here to the far edge of what's called a tuberosity where the rotator cuff inserts. So we have quite a large tear where the tendon is retracted almost all the way level back to the level of the socket. So this is gonna be a very large tear. As we go back, we can see the infraspinatus coming around the back of the shoulder, again, muscle in gray. Tendon in black, and that is all intact. So, so far we have a tear of the upper subscapularis and a tear of the supraspinatus tendon, with particularly the supraspinatus tendon being pulled back to the level of the socket. The other thing we can note in addition to tear size is we can make some notations about tendon quality, and this tendon appears thin relative to normal tendon. So this is going to present some challenges for repair when it comes to do that procedure. Next, I'll move on to what's called the sagittal images. Now, sagittal images are going from the side, so picture outside in as if somebody is standing. We're going to look at the front of the shoulder. The front of the shoulder here is the biceps tendon coming up, and then the back of the shoulder. So the back of the shoulder here, we see the infraspinatus tendon. As you can see here, this infraspinatus tendon is intact, coming all the way around. But right here on the top of the shoulder, the supraspinatus tendon is absent. You see this white signal showing a tear of that anterior or front leading edge of the supraspinatus tendon. Next, I want to finally look at what's called the muscle quality. This is done on the T1 sagittal image, and this is really important for determining repairability and the potential for healing of the rotator cuff. So I like to scroll over to this view here, which is essentially called a Mercedes BEN sign view. And what that is, is that represents the bone. And the bone here is the scapula. This is the, the bone through which the rotator cuff muscle runs. We can see in the front aspect here of the shoulder, this is the subscapularis tendon just on the, uh, left side, as you can see here. And there's just a very slight amount of what we call fat infiltration. That means white streaks in this normally gray muscle. But if we look up top and in the back, we can see that there's a fair amount of fatty infiltration of the supraspinatus and infraspinatus. So here on the supraspinatus, we have atrophy, meaning that the muscle is shrunk down. We have white space around as well as fatty infiltration within the muscle itself. We see similar findings, although less severe, in the infraspinatus tendon in the back here. So in summary, infraspinatus tendon muscle, that is. So in summary here, we have a large tear of the rotator cuff that involves the subscapularis tendon and the supraspinatus tendon. There's some associated fatty infiltration or atrophy of the rotator cuff. So this is gonna be a technical challenge if somebody wants to have surgery, as this individual did, where we have to address not only the tear size and the pattern by addressing the subscapularis and the supraspinatus tendon, But we also have to consider in this particular case, is there something we need to do to improve healing such as augmentation, which we ultimately selected for this individual because I can use scoring systems and in this particular case calculate that based on the tear size and the muscle quality, this individual's chances for healing with the standard repair are lower. So we chose to use augmentation in this particular case. And she ended up having an excellent outcome. But hopefully that gives you an overall view of how I approach MRI the rotator cuff. Again, looking at the patient, starting with the axillary view, then going to assessing the superior rotator cuff, which gives me more view of the tendon tear size and the tendon quality. And then finally looking at the muscle quality, which really plays into healing potential. Thank you very much.
