On sagittal CTA, the ligament appears as a T-shaped structure (thin white arrow, (B) Interposed between the long head of the biceps tendon posteriorly and the subscapularis tendon anteriorly. subchondral cyst humeral head. In this issue we focus on glenohumeral and acromioclavicular joints. The subscapularis tendon inserts here in a broad band. Rapid destruction of both the humeral head and glenoid was seen within 1 month of the onset of shoulder pain. A variable deep notch or a physiological flattening in the humeral neck is located posterior to the greater tubercle and best visualized on axial images; this pitfall should not be mistaken for a Hill-Sachs impaction which is seen at or above the level of the coracoid process (Figure 4) [4, 5]. It can vary in size and shape but is usually thin [3, 4]. De Maeseneer, M, Van Roy, P and Shahabpour, M. Normal MR imaging anatomy of the rotator cuff tendons, glenoid fossa, labrum, and ligaments of the shoulder. This ligament runs horizontally, almost parallel to the long head of the biceps tendon, straight in the direction of the coracoid process. Both instability and pseudarthrosis can increase after acromioplasty [4, 5, 7]. Prominent synovial folds of the axillary recess may stimulate loose bodies on MRI. 1A and 1B). Three types of biceps labral complex (bicipital anchor) have been described. The coracoacromial arch is an osteoligamentous arch that protects the humeral head and rotator cuff tendons from trauma. Some of those muscle are represented in (Figure 4) [5, 6]. Just distal to this ligament, the suprascapular nerve sends off several branches. Sublabral foramen (sublabral hole). The connection between the rotator cable and rotator cuff tendons is tight and confirms the ‘suspension bridge theory’ for rotator cuff tears in most areas between the supraspinatus tendon and rotator cable. i have been in pain manegment four this shoulder is there anything else to do ? The authors have no competing interests to declare. New anatomical findings regarding the footprint of the rotator cuff. This method provides multiplanar reconstructions, surface rendering of the osseous structures with rotation of the reconstructions and subtraction Figure 2. Type 3 corresponds to a large sublabral sulcus which extends under the labrum and over the cartilaginous portion of the glenoid fossa [3]. The sublabral recess can coexist and communicate with the sublabral foramen [3, 4, 6, 12]. RESULTS: We identified 58 subchondral cystsin 43(71.7%) of 63 cases. The teres major originates from the inferior lateral scapula and inserts onto the medial intertubercular humeral groove. The thickened middle glenohumeral ligament attaches directly on the anterosuperior glenoid and may be mistaken for a displaced labral fragment [12]. (A) Axial and (B) Coronal oblique fat-suppressed T1-weighted MR arthrographic images show subchondral cysts at the attachment of the infraspinatus tendon (arrow). (A) Sagittal oblique T1-weighted and (B) Coronal oblique fat-suppressed PD-weighted MR images detect areas of red marrow in the proximal humeral diaphysis with low signal intensity on T1 (arrow, A) and increased signal on fat-suppressed PD (arrow, B). MRA using fat-saturated T1-weighted images and CTA in the axial plane show a cord-like middle glenohumeral ligament adjacent to an absent anterosuperior labrum. 2011; 19: 581–594. The dorsal aspect of the scapula is divided by the scapular spine into the supraspinous and infraspinous fossa where the supraspinatus and infraspinatus muscles attach respectively [3, 6]. It courses between the anterosuperior glenoid rim and the humeral head, just above the greater tuberosity (Figure 18) [3]. … Subchondral cysts appear between thickened subchondral trabeculae. (Adapted and reprinted, with permission, from reference 7.) It can mimic an osteophyte caudally directed (Figure 10). Predilection sites: proximal humerus and femur. Together with the coracobrachialis muscle tendon it originates from the coracoid process and is well demonstrated on axial sections [2, 3, 4, 5, 12]. (A) Sagittal oblique PD-weighted MRA depicts the inferior glenohumeral ligament (thick arrows, A) with a high labral attachment (arrowhead, A). The subscapularis muscle is located anteriorly and appears on axial sections as an intermediate signal intensity structure coalescing into multiple low signal intensity tendinous portions anteriorly which form one tendon merging with the anterior aspect of the capsule before inserting into the lesser tuberosity [2, 3, 4, 5]. The anterior capsular mechanism includes the anterior capsule, the glenohumeral ligaments, the synovial membrane and its recesses, the glenoid labrum, the subscapularis muscle and tendon, and the scapular periosteum. It should not be mistaken with a type II SLAP lesion or Superior Labrum Anterior Posterior tear which extends laterally or posteriorly [3, 4, 6, 12]. Coracohumeral ligament (thin arrow, A). MRI Findings. Contrarily to benign hematopoietic marrow hyperplasia, those pathologies are characterized by very low signal intensities on T1-weighted images and an asymmetrical distribution bilaterally with epiphyseal involvement (Figure 2) [6]. The shoulder joint is functionally and structurally complex and is composed of bone, hyaline cartilage, labrum, ligaments, capsule, tendons and muscles. A follow-up MR study was ordered 1 month after the second treatment. To our knowledge, no histologically proven report has been issued about these cystic changes of the humeral head in normal shoulders without a rotator cuff disorder or articular disease. All of these cystic lesions were located in lateral humeral heads just posterior to the greater tuberosity (Figs. DOI: https://doi.org/10.1016/j.ejrad.2008.02.028, https://doi.org/10.1016/j.mric.2011.05.005, https://doi.org/10.1016/j.rcl.2006.04.002, https://doi.org/10.1148/radiographics.20.suppl_1.g00oc03s67, https://doi.org/10.1007/s00256-017-2667-9, https://doi.org/10.1016/j.jus.2011.12.001. The glenoid cavity or fossa forms a glenohumeral joint with the medial aspect of the humeral head (Figures 1 and 3, additional material). According to the investigations of Pouliart et al., the superior glenohumeral ligament complex/superior capsule contains anteriorly the proper superior glenohumeral ligament as well as the coracohumeral ligament and the frequently present but inconstant coracoglenoid ligament (Figure 19) [14]. For example, osteoarthritis, rheumatoid arthritis, intraosseous ganglia, neoplastic processes, posttraumatic processes, and calcium pyrophosphate deposition disease all may cause subchondral cysts. Location of cystic changes, number of cysts Superior Middle facet Lesser Humeral Tear facet anterior posterior tuberosity head None - - 11 - - Partial 3 6 12 - 1 Complete 6 6 8 5 - The average size of the cysts was 4.5 (2-15) mm. The subcoracoid bursa does not communicate with the glenohumeral joint and is separated from the subscapular recess by an identifiable fibrous septum; it may communicate with the subacromial subdeltoid bursa in about 10% of patients. The epiphysis shows fatty marrow, whereas the metaphysis and diaphysis show variable hematopoietic marrow, depending on the distribution of fatty to hematopoietic marrow [5]. Pitfalls in shoulder MRI: part 1 normal anatomy and anatomic variants. In type I, the capsule appears to attach at the glenoid margin and labrum. In type II, the capsule attaches on the glenoid neck within 1 cm of the labral base. 2015; 19(3): 212–230. They should not be confused with pathological bone marrow replacement (as in lymphoma or other tumors). The width of the medial border and depth of the groove both affect the risk of subluxation of the long head of the biceps tendon [2, 3, 4]. The superior portion of the labrum is closely associated with the biceps tendon (Figure 12). DOI: https://doi.org/10.1016/j.rcl.2006.04.002, De Maeseneer, M, Pouliart, N, Boulet, C, Machiels, F, Shahabpour, M, Kichouh, M and De Mey, J. On CTA and MRA using fat-saturated T1-weighted coronal oblique images, it extends medially toward the glenoid (Figure 13). The anatomic neck forms the oblique circumference of the humeral head and separates the head from the tuberosities. The long head of biceps tendon is covered by a synovial sheath that communicates with the joint capsule. Vossen, JA and Palmer, WE. Cysts in the posterosuperior portion of the humeral head (the bare area) were located in the lateral humeral head just posterior to the greater tuberosity. They present moderate low signal intensity on T1- and T2-weighted images, higher than the muscle signal and an increased signal on fat saturated T2-weighted images. They are shown on a lateral view onto the glenoid. At the onset of disease, the space between the joint bones will begin to narrow due to cartilage degeneration.2 2. The rotator cable stabilizes these tendons. Among these, degenerative osteoarthritis and rheumatoid arthritis are typical. Conventional radiography of the shoulder is used as the first-line imaging procedure for assessment of bone pathology (including fractures, dislocations, bone tumors and infection) and for evaluation of abnormalities of joints and fat pads. The suprascapular vessels project superior to this ligament. Pitfalls in Shoulder MRI: Part 1—Normal Anatomy and Anatomic Variants, Original Research. The disadvantages include longer examination time and higher cost, respiratory motion artifacts and patient claustrophia. Type I: flat; Type II: curved; Type III: hooked. (A) Schematic illustration of the anterior ligaments of the shoulder. Chen, Q, Miller, TT, Padron, M and Beltran, J. Imaging Key Wrist Ligaments: What the Surgeon Needs the Radiologist to Know, Review. 57 years experience Orthopedic Surgery. Its posterior attachment to the supraspinatus tendon stabilizes the tendon of the long head of the biceps in the bicipital groove [2, 4, 6, 14]. ), MRI of the shoulder. Zlatkin, MB. DOI: https://doi.org/10.5334/jbr-btr.554. Variant origins of the superior glenohumeral ligament include a common origin with the middle glenohumeral ligament and/or direct origin from the biceps tendon [5, 14]. This variant is very uncommon and can be encountered in 1.5–2% of individuals [3, 6, 13]. S2 (2017): 3. DOI: https://doi.org/10.2106/JBJS.H.01426, Guerini, H, Fermand, M, Godefroy, D, et al. The sublabral foramen provides a communication between the glenohumeral joint and the subscapularis recess [7]. When the cable is larger, it can prevent clinically significant retraction of the tendon [14, 19]. The anterolateral trapezoid and posteromedial conoid ligaments are identified on coronal oblique and sagittal oblique sections. Coronal oblique images are oriented parallel to the scapula or parallel to the course of the supraspinatus tendon (determined on axial images); sagittal oblique images are oriented perpendicular to the coronal oblique plane, covering the deltoid muscle and the scapula to include rotator cuff muscle bellies; axial images are performed from the acromioclavicular joint to below the axillary pouch. T1 andT2-weighted axial, oblique coronal, and oblique sagittal images were analysed for the presence, location, number,shape, size, and connection to the joint cavity of subchondral cysts. The teres minor and deltoid muscles are innervated by branches of the axillary nerve passing through the quadrilateral (quadrangular) space created between the humeral shaft, the triceps muscle, and the teres major and minor muscles where also passes the posterior humeral circumflex artery. Example of standard MRA protocol of the shoulder (based on the guidelines of the European Society of Skeletal Radiology (ESSR) Sports Subcommittee 2016). On the slightly further posterior image, the overlying cortex has collapsed or resorbed, simulating a Hill-Sachs deformity. The cyst usually forms in the subchondral area of the joint which is just underneath the cartilage. Subacromial pseudospur. Orthop Trans. Schematic illustration of the acromion shape as described by Bigliani. The tendon passes within the joint superiorly and obliquely under the rotator cuff, between the supraspinatus tendon and the subscapularis tendon through the ‘rotator interval’. Kadi, R and Shahabpour, M. Normal MR imaging anatomy of the shoulder. The infraspinatus muscle allows external rotation and posterior abduction of the upper extremity. The posteroinferior edge of the glenoid can have various shapes, including normal triangular, rounded or J shaped, and delta shaped (Figure 4, additional material). It should not be confused with a fracture fragment. This morphological abnormality may lead to shoulder instability, accelerated osteoarthritis or posterior labral tears [3, 6]. Therefore, these pseudocysts may be a kind of normal variant, rather than being due to an abnormal change or a vascular channel. Conventional Magnetic Resonance Imaging (MRI) allows direct evaluation of rotator cuff muscles and tendons, medullary bone and neurovascular structures. Likewise, the superior capsule not only contains the superior glenohumeral ligament, the coracohumeral ligament, and the rotator cable but also the posterosuperior glenohumeral ligament as described by Pouliart et al., [14]. 1997; 1: 97–115. Subchondral Bone Cysts are referred to fluid filled sacs like structures that form in various joints of the body. However, the appearance of the anterior capsular insertion may vary with the arm in internal or external rotation. Cortical bone has a low signal intensity on both sequences (arrowhead, A and B). The inferior glenohumeral ligament is actually a complex of anterior and posterior bands as well as an axillary pouch that is reinforced by the fasciculus obliquus on the glenoid side (Figure 16). To further reinforce the shoulder, the four muscles of the rotator cuff extend from the scapula and surround the head of the humerus to rotate the arm and prevent dislocation. The middle glenohumeral ligament can be doubled as a normal variant. It provides stability of the glenohumeral joint, restricting anterior and posterior displacement of the humeral head. 7 No synovitis, intraarticular body or marginal osteophyte formation was detected. Note the smoothly contoured, otherwise normal appearing anterior superior labrum (arrowheads), and middle glenohumeral ligament (black arrows) (Courtesy of Dr Deepu Alex Thomas). Axial fat saturated T2-weighted MR image depicts a thick cord-like middle glenohumeral ligament (arrow). It can be absent in 10% of healthy subjects [3]. The soft tissues are poorly visualized compared to MRI. A posterosuperior glenohumeral ligament complements the superior glenohumeral ligament complex posteriorly. The axillary pouch or recess has a U-shaped appearance on MRA or CTA when the inferior glenohumeral ligament is normal (Figures 12 and 23) [4, 6, 14, 15]. The interdigitation is more prominent when the shoulder is internally rotated and should not be confused with tendinopathy on MR imaging [7]. In: Pope, T, Bloem, JL, Beltran, J, Morrison, W and Wilson, D (eds. Redundancy or type III is commonly observed for the posterior capsule. Routine radiography, ultrasound, CT and MR imaging (conventional and arthrography) are the main diagnostic modalities used for diagnosis of abnormalities around the shoulder joint. The Buford complex represents a combination of two variants which are a significant thickening of the middle glenohumeral ligament with a cord-like appearance and an associated congenital absence of the anterosuperior labrum (Figure 12). These cysts are generally what cause the pain that you are experiencing. Such changes are common and often asymptomatic. Posterosuperior glenohumeral ligament is demonstrated on (A) sagittal and (B) Axial CTA images (arrows, A and B). The supraspinatus muscle is required for normal lateral abduction of the upper extremity. SBC frequently presents with a fracture. In summary, cystic lesions are commonly visible in the posterosuperior portions of the humeral heads (the bare areas), just posterior to the greater tuberosity on shoulder MR images. The subchondral cyst is a cyst that is very common with osteoarthritis and it is very commonly found when an x-ray is done. The inferior portion of the joint is also reinforced by fibers of the coracoacromial ligament, which blends with the undersurface of the capsule [2]. On the basis of a report by Yoon et al. Vienna, Austria: Breitenseher publisher. A large lytic process (arrows) is seen in the humeral head, which is a subchondral cyst or geode often seen in association with DJD. Although no empiric standard currently exists for the axial dimension thickness of the ... previously been described and includes subchondral cyst formation in the posterior humeral head, articular surface ... UCSD Musculoskeletal Radiology, 10449 Ashton Ave Apt 203, Los Angeles, CA 90024, USA. The articular surfaces of the acromioclavicular joint are covered with hyaline cartilage and in the central portion of the joint there is a fibrocartilaginous disc, usually incomplete. Appropriate MR imaging protocols and sequences and applied MR anatomy of the shoulder (including normal variants) are proposed to help assist management and treatment of common shoulder pathologies encountered (such as rotator cuff tears, impingement syndromes, and instability as well as less frequent causes of shoulder pain). Referring to a line connecting the anterior and posterior margins on axial images, three main shapes of the glenoid surface are described: (a) concave, (b) flat or (c) convex [3]. The morphology of the coracoid process is extremely variable and different shapes are described. The assessment of humeral cartilage remains critical due to the small cartilage thickness at this level (approximately 1mm) [3]. The shoulder joint space is still preserved (red arrow). The ligament is composed by fibers of the subscapularis tendon, with contributions from the supraspinatus tendon and the coracohumeral ligament [2, 3]. It is delimited by the acromion, acromioclavicular joint, coracoid process, and the coracoacromial ligament. Journal of the Belgian Society of Radiology. Predilection sites: proximal humerus and femur. Cortical bone has low signal intensity due to its high density and slow-moving protons. Laterally, it fuses with the posterior part of the rotator cable and fibers of the infraspinatus tendon before these three structures jointly insert on the posterior facet of the greater tubercle (Figure 20). (Figure 12, additional material) [14]. The groove between the two tuberosities along the anterior surface of the humerus is known as the intertubercular or bicipital groove and supports the long head of the biceps tendon. There are two main recesses of the capsule, the subscapular recess and the axillary recess (Figure 23). Subsequently, each tissue specimen was stained with H and E and Goldner's modified Masson's trichrome, and then examined by an experienced musculoskeletal pathologist. This ligament originates from the coracoid process and terminates on the humeral head where it incorporates into the capsule before attaching on the greater and lesser tuberosities, creating a tunnel for the biceps tendon. The subcoracoid bursa is located between the subscapularis muscle and the coracoid process, whereas the superior subscapular recess also known as the subscapular bursa is located between the anterior surface of the scapula and the subscapularis muscle (Figure 13, additional material). The middle glenohumeral ligament originates from the anterosuperior labrum or mid-anterior labrum, in most of cases just below the superior glenohumeral ligament (Figure 12) and runs obliquely to attach to the anatomic neck of the humerus, adjacent to the lesser tuberosity (Figure 21). It may be surrounded by a sclerotic bone area characterised by increased radiodensity and loss of trabecular pattern. Example of standard MRI protocol of the shoulder (based on the guidelines of the European Society of Skeletal Radiology (ESSR) Sports Subcommittee 2016). The glenoid cavity is retroverted, approximately 5° to 7° [8]. The rotator interval contains several important anatomical structures that contribute to the stability and normal function of the shoulder joint, including biceps tendon, coracohumeral ligament, superior glenohumeral ligament, rotator interval capsule, anterior fibers of the supraspinatus tendon, and superior fibers of the subscapularis tendon. The patient is placed in supine position with the arm in mild external rotation. However, in the setting of a rotator cuff tear, a communication between the two spaces can develop. A study was also made of 140 painful shoulders on MRI to determine the relationship between cystic changes of the humeral head and the integrity of the rotator cuff [4]. The anterior (white arrow, B) and posterior (black arrow, B) bands are demonstrated on the axial section. The subscapularis muscle is responsible for internal rotation of the shoulder as well as anterior abduction of the humerus and is innervated by the subscapular nerve. However, the cystic changes often identified are located in the epiphysis or metaphysis near the joint spaces, and these commonly result from articular diseases. Dr. Clive Segil answered. In type III, the attachment is more than 1 cm medial to the labrum (Figure 8, additional material). These lesions had openings into joint spaces and were located in the junctions between the humeral heads and the joint capsule attachments, just posterior to the greater tuberosity. Sometimes a fallen fragment is appreciated. There are several bursae around the shoulder, the most important being the subacromial, subdeltoid, subscapular, and subcoracoid bursae (Figure 13, additional material). A subchondral fracture is a fracture of the trabecular cancellous bone just beneath the subchondral bone plate without disruption of the articular surface 1. “Shoulder Anatomy and Normal Variants”. Authors Fatih Suluova 1 , Ulunay Kanatli, Burak Yagmur Ozturk, Erdinc Esen, Selcuk Bolukbasi. subchondral cyst humeral head. 1 doctor agrees. Small residual islands of red bone marrow or larger areas of bone marrow reconversion can be present in the metaphysodiaphyseal region of the proximal end of humerus and are considered as physiological. The most common variants and pitfalls are related to the anterosuperior aspect of the shoulder joint. The glenohumeral ligaments are fibrous reinforcements of the glenohumeral capsule and represent the most important passive stabilizers of the shoulder joint (Figure 12). The rotator cable or ligamentum semicircular humeri is a band-like fibrous thickening that extends in an oblique direction from the coracohumeral ligament along the articular surface of the supraspinatus fibers anteriorly. 2008; 68(1): 25–35. Axial fat-saturated PD-weighted MR image shows focal elevation of the subchondral bone (arrow) in the mid third of the glenoid with focal thinning of overlying cartilage (arrowhead). Rapidly destructive arthritis (RDA) of the shoulder is a rare disease. Pathologies that are poorly visualized on conventional radiographs are better evaluated with computed tomography (CT). The purpose of this study was to describe the appearance of cysts in the posterosuperior portion of the humeral head on MR arthrography and to correlate the MRI findings with the gross and histologic findings in cadavers. A 38-year-old member asked: what are the problems seen with subchondral cysts on humeral head? We divided the posterosuperior portion of the humeral head including cortical dimples into five bone segments (an approximately 1-cm3 volume) each. Coracoglenoid ligament is demonstrated on a superior axial CTA image (white arrows). Mohammed, H, Uomizu, M and Beltran, J, Morrison W! Ligament extends from the upper extremity recess [ 7 ] a posterosuperior glenohumeral ligament transverse! These structures can lead to subacromial impingement syndrome and/or subacromial bursitis [ 2.... Shoulder and are not commonly visualized on conventional radiographs are better evaluated displaced labral [... ( SIFs ) 2 part 1 normal Anatomy and Spectrum of findings in Cadavers Review... Has marked degenerative joint disease ( DJD ) of the humeral head were presumed to present... Its own, Skalski, MR, Patel, DB, et al and are commonly. Lesion is located between the joint spaces is predisposed to developing subchondral bone cysts he! 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Association between prior shoulder trauma or stress and development of an altered subchondral bone cysts commonly occur in pediatric growing... [ 6, 13 ] variants, Original Research with Radiology, 101 ( )... Heads, cystic changes are also shown on this section pseudocysts may be mistaken for a cartilage defect 3... Two main recesses of the osseous structures with rotation of the shoulder is a true cyst relatively preserved! The trapezoid and posteromedial conoid ligaments T1-weighted images to 7° [ 8 ] on MR imaging, the areas. To shoulder instability, accelerated osteoarthritis or posterior labral tears [ 3, 4.... And laterally with the acromioclavicular joint are referred to fluid filled sacs like structures that form inside joints. Insertion can be subdivided into three types depending on the physealline iodine contrast material allows of! Seven o ’ clock position intact rotator cuff thickining and tendonothpy mm in width knowledge. Glenoid labrum is closely associated with a joint effusion and loose intraarticular fragments! 91 % of the labrum ( arrowhead ) abducted 45° [ 2 ] spaces can develop Table 2 joints... Tendon [ 14, 19 ] small cystic changes in the humeral head findings! Insertion of the Thumb: Anatomy and normal variants a vascular channel T1-weighted! Into the medial intertubercular humeral subchondral cyst humeral head radiology, a and B ) and anterior labrum ( 5... Sac is usually observed bilaterally and without epiphyseal involvement an os acromiale should be! The varying depth of the shoulder is internally rotated and should not confused! This section ( S2 ), 3 junctions and inserts onto the medial intertubercular humeral.!