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Rotator Cuff: Evaluation with US and MR Imaging¹

¹ From the Departments of Radiology (C.J.S., T.A.M., S.J.E., M.E.T.) and Orthopaedics (W.G.R.), Froedtert Memorial Lutheran Hospital, 9200 W Wisconsin Ave, Milwaukee, WI; and Vermont Orthopaedic Clinic, Rutland (M.D.B.). Recipient of a Cum Laude award for a scientific exhibit at the 1997 RSNA scientific assembly. Received May 13, 1998; revision requested June 5 and received August 13; accepted August 20. Address reprint requests to S.J.E.

View larger version (130K): [in a new window]   Figure 1a.  Patient positioning with MR and US imaging. (a) Oblique coronal proton-density–weighted MR image obtained with the arm at the side and in neutral position shows relatively limited exposure of the rotator cuff (arrows in a–d) lateral to the acromion (A in a–d). (b) US image obtained with the arm at the side, palm up, similarly demonstrates relatively limited exposure of the cuff lateral to the shadowing acromion. (c) Oblique coronal proton-density–weighted MR image obtained with the arm in external rotation shows greatly increased exposure of the cuff lateral to the acromion. (d) Extended-field-of-view US image obtained with the hand positioned behind the back demonstrates increased exposure of the cuff lateral to the shadowing acromion.

View larger version (122K): [in a new window]   Figure 1b.  Patient positioning with MR and US imaging. (a) Oblique coronal proton-density–weighted MR image obtained with the arm at the side and in neutral position shows relatively limited exposure of the rotator cuff (arrows in a–d) lateral to the acromion (A in a–d). (b) US image obtained with the arm at the side, palm up, similarly demonstrates relatively limited exposure of the cuff lateral to the shadowing acromion. (c) Oblique coronal proton-density–weighted MR image obtained with the arm in external rotation shows greatly increased exposure of the cuff lateral to the acromion. (d) Extended-field-of-view US image obtained with the hand positioned behind the back demonstrates increased exposure of the cuff lateral to the shadowing acromion.

View larger version (156K): [in a new window]   Figure 1c.  Patient positioning with MR and US imaging. (a) Oblique coronal proton-density–weighted MR image obtained with the arm at the side and in neutral position shows relatively limited exposure of the rotator cuff (arrows in a–d) lateral to the acromion (A in a–d). (b) US image obtained with the arm at the side, palm up, similarly demonstrates relatively limited exposure of the cuff lateral to the shadowing acromion. (c) Oblique coronal proton-density–weighted MR image obtained with the arm in external rotation shows greatly increased exposure of the cuff lateral to the acromion. (d) Extended-field-of-view US image obtained with the hand positioned behind the back demonstrates increased exposure of the cuff lateral to the shadowing acromion.

View larger version (114K): [in a new window]   Figure 1d.  Patient positioning with MR and US imaging. (a) Oblique coronal proton-density–weighted MR image obtained with the arm at the side and in neutral position shows relatively limited exposure of the rotator cuff (arrows in a–d) lateral to the acromion (A in a–d). (b) US image obtained with the arm at the side, palm up, similarly demonstrates relatively limited exposure of the cuff lateral to the shadowing acromion. (c) Oblique coronal proton-density–weighted MR image obtained with the arm in external rotation shows greatly increased exposure of the cuff lateral to the acromion. (d) Extended-field-of-view US image obtained with the hand positioned behind the back demonstrates increased exposure of the cuff lateral to the shadowing acromion.

View larger version (146K): [in a new window]   Figure 2a.  Comparison of the minimal field of view achievable with MR imaging versus that with US. (a) On the oblique coronal MR image, the minimal field of view extends medial to the glenoid cavity. Note the shelflike insertion site (arrows). (b) On the coronal (longitudinal) US image, field-of-view coverage extends to approximately the midarticular aspect of the humeral head, and the shelflike insertion is well depicted (arrows). Spatial resolution is superior to that of MR imaging.

View larger version (121K): [in a new window]   Figure 2b.  Comparison of the minimal field of view achievable with MR imaging versus that with US. (a) On the oblique coronal MR image, the minimal field of view extends medial to the glenoid cavity. Note the shelflike insertion site (arrows). (b) On the coronal (longitudinal) US image, field-of-view coverage extends to approximately the midarticular aspect of the humeral head, and the shelflike insertion is well depicted (arrows). Spatial resolution is superior to that of MR imaging.

View larger version (73K): [in a new window]   Figure 3. Figures 3, 4. (3) Drawing shows the coracoacromial arch, deltoid muscle, rotator cuff, and intervening subacromial-subdeltoid bursa. (4) Coronal (longitudinal) US image shows the hypoechoic subacromial-subdeltoid bursa (solid straight arrows) interposed between hyperechoic layers. The adjacent deltoid muscle (solid curved arrows) and the echogenic rotator cuff (open arrows) are also seen.

View larger version (134K): [in a new window]   Figure 4. Figures 3, 4. (3) Drawing shows the coracoacromial arch, deltoid muscle, rotator cuff, and intervening subacromial-subdeltoid bursa. (4) Coronal (longitudinal) US image shows the hypoechoic subacromial-subdeltoid bursa (solid straight arrows) interposed between hyperechoic layers. The adjacent deltoid muscle (solid curved arrows) and the echogenic rotator cuff (open arrows) are also seen.

View larger version (52K): [in a new window]   Figure 5.  Drawing shows the right shoulder from above with the four rotator cuff components merging to form a "hood" over the humeral head.

View larger version (152K): [in a new window]   Figure 6a.  Two tendinous components of the supraspinatus tendon. (a) Oblique sagittal proton-density–weighted MR image shows the anterior "cylindric" (solid straight arrows) and posterior "flat" (curved arrows) contributions of the supraspinatus tendon. The fibers of the infraspinatus tendon (open arrows) interdigitate with the supraspinatus tendon. (b) Corresponding US image shows the cylindric (straight arrows) and flat (curved arrows) contributions of the supraspinatus tendon.

View larger version (137K): [in a new window]   Figure 6b.  Two tendinous components of the supraspinatus tendon. (a) Oblique sagittal proton-density–weighted MR image shows the anterior "cylindric" (solid straight arrows) and posterior "flat" (curved arrows) contributions of the supraspinatus tendon. The fibers of the infraspinatus tendon (open arrows) interdigitate with the supraspinatus tendon. (b) Corresponding US image shows the cylindric (straight arrows) and flat (curved arrows) contributions of the supraspinatus tendon.

View larger version (148K): [in a new window]   Figure 7a.  Peri-insertional rotator cuff complexity. (a) Oblique sagittal proton-density–weighted MR image shows the complex appearance of the merging cuff tendons (arrows). This appearance may be observed on clinical images in which high-resolution technique is used. (b) Transverse US image shows the complex "fibrillar" appearance of the rotator cuff (straight arrows) between the overlying deltoid muscle (D) and the underlying humeral head (curved arrows).

View larger version (129K): [in a new window]   Figure 7b.  Peri-insertional rotator cuff complexity. (a) Oblique sagittal proton-density–weighted MR image shows the complex appearance of the merging cuff tendons (arrows). This appearance may be observed on clinical images in which high-resolution technique is used. (b) Transverse US image shows the complex "fibrillar" appearance of the rotator cuff (straight arrows) between the overlying deltoid muscle (D) and the underlying humeral head (curved arrows).

View larger version (182K): [in a new window]   Figure 8a.  Subscapularis tendon in external rotation. (a) Axial proton-density–weighted MR image shows the subscapularis tendon (straight black arrows), coracoid process (curved arrow), and tendinous insertion (white arrow). (b) Transverse US image shows the subscapularis tendon (straight solid arrows), proximal muscle (curved arrows), shadowing coracoid process (open arrows), and insertion site (arrowheads).

View larger version (113K): [in a new window]   Figure 8b.  Subscapularis tendon in external rotation. (a) Axial proton-density–weighted MR image shows the subscapularis tendon (straight black arrows), coracoid process (curved arrow), and tendinous insertion (white arrow). (b) Transverse US image shows the subscapularis tendon (straight solid arrows), proximal muscle (curved arrows), shadowing coracoid process (open arrows), and insertion site (arrowheads).

View larger version (142K): [in a new window]   Figure 9a.  Subscapularis insertion. (a) Oblique sagittal proton-density–weighted MR image shows the complex insertion site of the subscapularis tendon (straight arrows). The appearance of the distal supraspinatus and infraspinatus tendons is similar (curved arrows). (b) Sagittal (cross-sectional) US image shows similar heterogeneity of the subscapularis tendon near the insertion site on the lesser tuberosity (arrows).

View larger version (144K): [in a new window]   Figure 9b.  Subscapularis insertion. (a) Oblique sagittal proton-density–weighted MR image shows the complex insertion site of the subscapularis tendon (straight arrows). The appearance of the distal supraspinatus and infraspinatus tendons is similar (curved arrows). (b) Sagittal (cross-sectional) US image shows similar heterogeneity of the subscapularis tendon near the insertion site on the lesser tuberosity (arrows).

View larger version (0K): [in a new window]   Figure 10.  Permission to reprint this figure electronically was denied by the publisher. See print version.

View larger version (74K): [in a new window]   Figure 11.  Drawing shows the anatomic characteristics of the rotator interval.

View larger version (150K): [in a new window]   Figure 12a.  Rotator interval. (a, b) Oblique sagittal proton-density–weighted MR image (a) and oblique sagittal fat-suppressed T1-weighted MR image obtained after intraarticular injection of dilute gadolinium (b) show the biceps tendon (straight arrow in a) coursing within the rotator interval deep to the capsule and coracohumeral ligament (curved solid arrows), anterior to the supraspinatus tendon (open arrows), and superior to the subscapularis tendon (arrowheads). (c) Transverse US image of the rotator interval shows the biceps tendon coursing between the supraspinatus (SUPRA) and subscapularis (SUBSCAP) tendons. The overlying capsule and coracohumeral ligament are visible (arrows).

View larger version (150K): [in a new window]   Figure 12b.  Rotator interval. (a, b) Oblique sagittal proton-density–weighted MR image (a) and oblique sagittal fat-suppressed T1-weighted MR image obtained after intraarticular injection of dilute gadolinium (b) show the biceps tendon (straight arrow in a) coursing within the rotator interval deep to the capsule and coracohumeral ligament (curved solid arrows), anterior to the supraspinatus tendon (open arrows), and superior to the subscapularis tendon (arrowheads). (c) Transverse US image of the rotator interval shows the biceps tendon coursing between the supraspinatus (SUPRA) and subscapularis (SUBSCAP) tendons. The overlying capsule and coracohumeral ligament are visible (arrows).

View larger version (112K): [in a new window]   Figure 12c.  Rotator interval. (a, b) Oblique sagittal proton-density–weighted MR image (a) and oblique sagittal fat-suppressed T1-weighted MR image obtained after intraarticular injection of dilute gadolinium (b) show the biceps tendon (straight arrow in a) coursing within the rotator interval deep to the capsule and coracohumeral ligament (curved solid arrows), anterior to the supraspinatus tendon (open arrows), and superior to the subscapularis tendon (arrowheads). (c) Transverse US image of the rotator interval shows the biceps tendon coursing between the supraspinatus (SUPRA) and subscapularis (SUBSCAP) tendons. The overlying capsule and coracohumeral ligament are visible (arrows).

View larger version (165K): [in a new window]   Figure 13a.  Rotator interval. (a) Oblique coronal T2-weighted MR image shows the biceps tendon (straight arrows) coursing just anterior to the supraspinatus tendon and capsule (curved arrows). The interface between these two structures is hyperintense fluid. (b) Coronal (longitudinal) US image shows a normal, hypoechoic fluid interface between the biceps tendon (straight arrows) and the anterior edge of the supraspinatus tendon (curved arrows).

View larger version (114K): [in a new window]   Figure 13b.  Rotator interval. (a) Oblique coronal T2-weighted MR image shows the biceps tendon (straight arrows) coursing just anterior to the supraspinatus tendon and capsule (curved arrows). The interface between these two structures is hyperintense fluid. (b) Coronal (longitudinal) US image shows a normal, hypoechoic fluid interface between the biceps tendon (straight arrows) and the anterior edge of the supraspinatus tendon (curved arrows).

View larger version (0K): [in a new window]   Figure 14. Figures 14, 15. Permission to reprint these figures electronically was denied by the publisher. See print version.

View larger version (0K): [in a new window]   Figure 15. Figures 14, 15. Permission to reprint these figures electronically was denied by the publisher. See print version.

View larger version (0K): [in a new window]   Figure 16a.  Rotator cable and crescent. (a) Permission to reprint this figure electronically was denied by the publisher. See print version. (b) Arthroscopic image (lateral on the right, medial on the left) shows the cable (arrows) and the lateral crescent (*). BT = biceps tendon, HH = humeral head.

View larger version (126K): [in a new window]   Figure 16b.  Rotator cable and crescent. (a) Permission to reprint this figure electronically was denied by the publisher. See print version. (b) Arthroscopic image (lateral on the right, medial on the left) shows the cable (arrows) and the lateral crescent (*). BT = biceps tendon, HH = humeral head.

View larger version (130K): [in a new window]   Figure 17a.  Fibrocartilaginous insertion of the supraspinatus tendon. (a) Photograph of a cryomicrotome section obtained from the cadaver of a 37-year-old woman shows the fibrocartilaginous insertion on the "shelf" (straight arrows), as well as the adjacent hyaline cartilage (curved arrows). The fascicles of the overlying supraspinatus tendon curve toward their attachment sites (arrowheads). (b) Permission to reprint this figure electronically was denied by the publisher. See print version. (c) Oblique coronal proton-density–weighted MR image shows the hypointense fibrocartilaginous insertion site (straight arrows) and adjacent hyaline cartilage (curved arrows). (d) Coronal (longitudinal) US image shows the hypoechoic fibrocartilaginous insertion site (straight arrows) as well as the adjacent, hypoechoic hyaline articular cartilage (curved arrows).

View larger version (0K): [in a new window]   Figure 17b.  Fibrocartilaginous insertion of the supraspinatus tendon. (a) Photograph of a cryomicrotome section obtained from the cadaver of a 37-year-old woman shows the fibrocartilaginous insertion on the "shelf" (straight arrows), as well as the adjacent hyaline cartilage (curved arrows). The fascicles of the overlying supraspinatus tendon curve toward their attachment sites (arrowheads). (b) Permission to reprint this figure electronically was denied by the publisher. See print version. (c) Oblique coronal proton-density–weighted MR image shows the hypointense fibrocartilaginous insertion site (straight arrows) and adjacent hyaline cartilage (curved arrows). (d) Coronal (longitudinal) US image shows the hypoechoic fibrocartilaginous insertion site (straight arrows) as well as the adjacent, hypoechoic hyaline articular cartilage (curved arrows).

View larger version (130K): [in a new window]   Figure 17c.  Fibrocartilaginous insertion of the supraspinatus tendon. (a) Photograph of a cryomicrotome section obtained from the cadaver of a 37-year-old woman shows the fibrocartilaginous insertion on the "shelf" (straight arrows), as well as the adjacent hyaline cartilage (curved arrows). The fascicles of the overlying supraspinatus tendon curve toward their attachment sites (arrowheads). (b) Permission to reprint this figure electronically was denied by the publisher. See print version. (c) Oblique coronal proton-density–weighted MR image shows the hypointense fibrocartilaginous insertion site (straight arrows) and adjacent hyaline cartilage (curved arrows). (d) Coronal (longitudinal) US image shows the hypoechoic fibrocartilaginous insertion site (straight arrows) as well as the adjacent, hypoechoic hyaline articular cartilage (curved arrows).

View larger version (132K): [in a new window]   Figure 17d.  Fibrocartilaginous insertion of the supraspinatus tendon. (a) Photograph of a cryomicrotome section obtained from the cadaver of a 37-year-old woman shows the fibrocartilaginous insertion on the "shelf" (straight arrows), as well as the adjacent hyaline cartilage (curved arrows). The fascicles of the overlying supraspinatus tendon curve toward their attachment sites (arrowheads). (b) Permission to reprint this figure electronically was denied by the publisher. See print version. (c) Oblique coronal proton-density–weighted MR image shows the hypointense fibrocartilaginous insertion site (straight arrows) and adjacent hyaline cartilage (curved arrows). (d) Coronal (longitudinal) US image shows the hypoechoic fibrocartilaginous insertion site (straight arrows) as well as the adjacent, hypoechoic hyaline articular cartilage (curved arrows).

View larger version (125K): [in a new window]   Figure 18a.  Magic angle effect. (a) Short-echo-time MR image obtained with the arm in neutral position shows a hyperintense focus approximately 1 cm proximal to the rotator cuff insertion (arrows). (b) On an MR image obtained with identical imaging parameters but with lateral flexion at the waist, the hyperintense region now extends to the insertion site (arrows). The change in position resulted in reorientation of the fibers in relation to the main magnetic field, causing a shift in the site of signal augmentation. (Fig 18a and 18b reprinted, with permission, from reference 21.)

View larger version (124K): [in a new window]   Figure 18b.  Magic angle effect. (a) Short-echo-time MR image obtained with the arm in neutral position shows a hyperintense focus approximately 1 cm proximal to the rotator cuff insertion (arrows). (b) On an MR image obtained with identical imaging parameters but with lateral flexion at the waist, the hyperintense region now extends to the insertion site (arrows). The change in position resulted in reorientation of the fibers in relation to the main magnetic field, causing a shift in the site of signal augmentation. (Fig 18a and 18b reprinted, with permission, from reference 21.)

View larger version (101K): [in a new window]   Figure 19.  Artifactual reduction in tendon echogenicity attributable to tendon anisotropy. Coronal (longitudinal) US image shows hypoechoic appearance of the distal rotator cuff tendon that extends to the insertion site (arrows). Compare this with the appearance of the rotator cuff in Figures 3b, 4, 6, and 21d. The examiner must make a conscious effort to continually reorient the US probe so that it is perpendicular to the direction of cuff fibers; otherwise, anisotropy may be mistaken for a cuff tear.

View larger version (114K): [in a new window]   Figure 20.  Calcific tendinitis. Coronal (longitudinal) US image of the rotator cuff shows an arcuate echogenic focus (straight arrows) with acoustical shadowing (curved arrows). This focus corresponds to an intratendinous calcium deposit that was removed at surgery.

View larger version (126K): [in a new window]   Figure 21.  Biceps tendon pitfall. On an oblique US image of the biceps tendon, the tendon may mimic the appearance of a torn and retracted supraspinatus tendon (arrows). Compare this image with Figure 16b, in which the hypoechoic interface between the anterior edge of the supraspinatus and biceps tendons may be mistaken for a longitudinal tear. The biceps tendon is, as a rule, more echogenic than the rotator cuff tendons (Craig J, oral communication, 1997).

View larger version (120K): [in a new window]   Figure 22.  Heterogeneity of the normal rotator cuff. Coronal (longitudinal) US image of a 16-year-old patient with a history of shoulder instability shows multiple hypoechoic zones (arrows) extending to the fibrocartilaginous insertion site. The cuff was normal at arthroscopy. Heterogeneity of the normal rotator cuff is attributable to complex interdigitation of intra- and intertendinous contributions.

View larger version (83K): [in a new window]   Figure 23.  Reproduction of page 101 from E. A. Codman's classic textbook (25) shows partial-thickness undersurface tears of the rotator cuff. Figure 1 demonstrates a subtle, undersurface lesion located at the capsular reflection. Figure 2 shows a more extensive, partial undersurface tear that involves approximately 50% of the cuff thickness ("rim-rent"). Figure 3 shows a yet more extensive partial, undersurface tear with delamination and retraction of the undersurface contribution (straight arrow). Figure 4 shows a lesion confined predominantly to the cuff substance. The secondary osseous changes are most conspicuous in Figures 2 and 3 (curved arrows).

View larger version (152K): [in a new window]   Figure 24. Figures 24, 25. Large, full-thickness tear of the rotator cuff. (24) Oblique coronal T2-weighted MR image shows a large cuff defect, with the edge retracted far medially (white arrows). Fluid is within both the glenohumeral joint and subacromial-subdeltoid bursa (black arrows). The overlying deltoid muscle (D) nearly apposes the humeral head. A large, full-thickness tear of the rotator cuff was verified at surgery. (25) Oblique coronal proton-density–weighted MR image shows the edges of the torn tendon contrasted with high-signal-intensity fluid. There is delamination, with the undersurface fibers (white arrow) retracted further medially than the bursal-sided fibers (black arrows). A large, full-thickness tear of the rotator cuff was verified at surgery.

View larger version (140K): [in a new window]   Figure 25. Figures 24, 25. Large, full-thickness tear of the rotator cuff. (24) Oblique coronal T2-weighted MR image shows a large cuff defect, with the edge retracted far medially (white arrows). Fluid is within both the glenohumeral joint and subacromial-subdeltoid bursa (black arrows). The overlying deltoid muscle (D) nearly apposes the humeral head. A large, full-thickness tear of the rotator cuff was verified at surgery. (25) Oblique coronal proton-density–weighted MR image shows the edges of the torn tendon contrasted with high-signal-intensity fluid. There is delamination, with the undersurface fibers (white arrow) retracted further medially than the bursal-sided fibers (black arrows). A large, full-thickness tear of the rotator cuff was verified at surgery.

View larger version (163K): [in a new window]   Figure 26.  Partial-thickness tear of the rotator cuff. Oblique coronal T2-weighted MR image shows an undersurface tear with a discrete flap (arrows) that was verified at surgery.

View larger version (144K): [in a new window]   Figure 27a.  Partial-thickness bursal-sided tears of the rotator cuff. (a) Oblique coronal proton-density–weighted MR image shows a defect that involves the bursal aspect of the cuff (black arrows). The bursal fibers are retracted and the gap is filled with hyperintense material. The undersurface fibers (curved arrow) appear attached lateral to the capsular reflection, which is demarcated by the hyaline cartilage margin (open arrow). A partial-thickness bursal-sided tear of the rotator cuff was verified at surgery. (b) Oblique coronal T2-weighted MR image shows an extensive, partial-thickness bursal-sided defect in which the bursal fibers (black arrows) are separated from their insertion site (curved arrow). A thin rim of intact deep cuff tissue remains (open arrows), and there is a large bursal effusion (*). A partial-thickness bursal-sided tear of the rotator cuff was verified at surgery.

View larger version (135K): [in a new window]   Figure 27b.  Partial-thickness bursal-sided tears of the rotator cuff. (a) Oblique coronal proton-density–weighted MR image shows a defect that involves the bursal aspect of the cuff (black arrows). The bursal fibers are retracted and the gap is filled with hyperintense material. The undersurface fibers (curved arrow) appear attached lateral to the capsular reflection, which is demarcated by the hyaline cartilage margin (open arrow). A partial-thickness bursal-sided tear of the rotator cuff was verified at surgery. (b) Oblique coronal T2-weighted MR image shows an extensive, partial-thickness bursal-sided defect in which the bursal fibers (black arrows) are separated from their insertion site (curved arrow). A thin rim of intact deep cuff tissue remains (open arrows), and there is a large bursal effusion (*). A partial-thickness bursal-sided tear of the rotator cuff was verified at surgery.

View larger version (129K): [in a new window]   Figure 28.  Large, full-thickness tear of the rotator cuff. Coronal (longitudinal) sonogram shows a large cuff defect filled with fluid and debris (straight arrows). Also apparent are the medially retracted edge of the supraspinatus tendon (curved arrow), near apposition of the deltoid muscle (D) to the humeral head, and loss of outer convexity. Compare this with the corresponding MR image shown in A large, full-thickness tear of the rotator cuff was verified at surgery.

View larger version (142K): [in a new window]   Figure 29a.  Massive full-thickness tear of the rotator cuff. (a) Coronal (longitudinal) US image demonstrates a massive rotator cuff tear, the gap filled with hypoechoic fluid (straight arrows). The underlying hyaline cartilage is exposed (naked cartilage sign) (curved arrows). (b) Coronal US image obtained with manual compression of the same region of the cuff shows apposition of the deltoid muscle (D) to the underlying humeral head (solid arrows). An osseous excrescence appears at the articular margin (open arrow). The patient in this case did not undergo surgery.

View larger version (139K): [in a new window]   Figure 29b.  Massive full-thickness tear of the rotator cuff. (a) Coronal (longitudinal) US image demonstrates a massive rotator cuff tear, the gap filled with hypoechoic fluid (straight arrows). The underlying hyaline cartilage is exposed (naked cartilage sign) (curved arrows). (b) Coronal US image obtained with manual compression of the same region of the cuff shows apposition of the deltoid muscle (D) to the underlying humeral head (solid arrows). An osseous excrescence appears at the articular margin (open arrow). The patient in this case did not undergo surgery.

View larger version (132K): [in a new window]   Figure 30a.  Full-thickness tear of the rotator cuff. (a) Coronal (longitudinal) US image shows a full-thickness defect of the rotator cuff filled with both fluid and debris (straight arrows). Delamination of the cuff is apparent, with more medial retraction of the deep (solid curved arrow) as opposed to the bursal (open arrow) aspect. In addition, the specular reflector of the articular surface abuts fluid, resulting in the naked cartilage sign (open arrowheads). There is minor osseous irregularity (solid arrowheads). (b) Corresponding arthroscopic image (lateral on the right, medial on the left) shows the large defect, which appears relatively dark (white arrows). The medially retracted edge of the tendon is visualized (black arrows). A = undersurface of the acromion; * = irregularities of the humeral head.

View larger version (61K): [in a new window]   Figure 30b.  Full-thickness tear of the rotator cuff. (a) Coronal (longitudinal) US image shows a full-thickness defect of the rotator cuff filled with both fluid and debris (straight arrows). Delamination of the cuff is apparent, with more medial retraction of the deep (solid curved arrow) as opposed to the bursal (open arrow) aspect. In addition, the specular reflector of the articular surface abuts fluid, resulting in the naked cartilage sign (open arrowheads). There is minor osseous irregularity (solid arrowheads). (b) Corresponding arthroscopic image (lateral on the right, medial on the left) shows the large defect, which appears relatively dark (white arrows). The medially retracted edge of the tendon is visualized (black arrows). A = undersurface of the acromion; * = irregularities of the humeral head.

View larger version (149K): [in a new window]   Figure 31. Figures 31, 32. (31) Partial, undersurface tear of the rotator cuff. Coronal (longitudinal) US image shows mixed echogenicity of the undersurface of the cuff (straight arrows) that reflects torn cuff fibers and adjacent fluid. The bursal fibers are intact (curved arrows). (Courtesy of Marnix van Holsbeeck, MD, Henry Ford Hospital, Detroit, Mich.) (32) Partial-thickness, undersurface tear of the rotator cuff. Transverse sonogram demonstrates a hypoechoic region (open arrow) along the undersurface of the supraspinatus tendon (SS). The adjacent greater tuberosity is pitted (solid arrows). The lesion was confirmed at arthroscopy. (Reprinted, with permission, from reference 38.)

View larger version (177K): [in a new window]   Figure 32. Figures 31, 32. (31) Partial, undersurface tear of the rotator cuff. Coronal (longitudinal) US image shows mixed echogenicity of the undersurface of the cuff (straight arrows) that reflects torn cuff fibers and adjacent fluid. The bursal fibers are intact (curved arrows). (Courtesy of Marnix van Holsbeeck, MD, Henry Ford Hospital, Detroit, Mich.) (32) Partial-thickness, undersurface tear of the rotator cuff. Transverse sonogram demonstrates a hypoechoic region (open arrow) along the undersurface of the supraspinatus tendon (SS). The adjacent greater tuberosity is pitted (solid arrows). The lesion was confirmed at arthroscopy. (Reprinted, with permission, from reference 38.)