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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

X-ray Findings in Rotator Cuff Tears / Impingement Syndrome


- See:
       - Shoulder Arthrography 
       - MRI

- Impingement Radiographic Series:
    - axillary view: may reveal an Os Acromiale, which is associated w/ impingment;
    - scapular outlet view
         - allows assessment of acromial morphology;
         - examination of cadavera reveal:
              - type 1, a flat acromion (17% of shoulders): 3% of all cuff tears have this type of acromion;
              - type 2, a curved acromion (43%): 27% of all cuff tears have this type of acromion;
              - type 3, a hooked acromion (40%): majority (70 - 90%) of rotator cuff tears may be seen in pts w/ type-2 or a type-3 acromion
                     - type A: less than 8 mm in thickness;
                     - type B: 8-12 mm thick;
                     - type C: greater than 12 mm in thickness;
              - references:
                    - The morphology of the acromion and its relationship to rotator cuff disease. Bigliani LU, et al. Orthop Trans. 1986;10:228. 
                    - The clinical significance of variations in acromial morphology. Morrison DS, Bigliani LU. Orthop Trans. 1987;11:234 
                    - A modified classification of supraspinatus outlet view based on configuration and anatomic thickness of acromion. Orthop. Trans. 767. 1992-1993.
    - 30 deg Caudal Tilt AP View: is taken tangential to dome of acromion to assess size of anterior inferior acromial osteophyte;
    - AP of the Shoulder
           - note that normal acromiohumeral interval is 1 to 1.5 cm;
           - other varients of the AP view is:
                  - internal rotation view;
                  - 35 deg external rotation;
                  - 90 deg abduction view;
                  - Grashey view:
                        - obtained w/ 30 deg lateral oblique projection, tangential to glenohumeral joint, in order to obtain view directly down joint to reveal any degenerative changes;
    - Active Abduction View 
    - West Point View: may be indicated in younger patients w/ suspected anterior instability;


- Specific Pathologic Findings:
    - AC joint arthrosis 
    - superior subluxation:
           - active abduction view 
           - decreased space between humerus & inferior portion of acromion;
           - usually indicates poor rotator cuff function, highly attenuated rotator cuff, or massive tear of rotator cuff;
           - pts w/o rotator cuff tears or with small to medium size tears may have normal appearing plain radiographs with an acromiohumeral interval of 1 to 1.5 cm;
           - when acromiohumeral interval measures < 5 mm or less, significant tear of the rotator cuff should be suspected;
           - disadvantages: this view can be unreliable due to position of the arm and x-ray tube;
    - osteoarthritic changes:
           - prominent osteophyte at the inferior margin of the humeral head or glenoid is characteristic;
           - mild arthrosis: inferior osteophyte less than 3 mm in length;
           - moderate arthrosis: inferior osteophyte between 3-5 mm in length, irregularity of the joint line and subchondral sclerosis;
           - severe arthrosis: inferior osteophyte measuring more than 5 mm or if there is joint incongruity;
    - greater tuberosity:
           - atrophy of greater tuberosity, cystic changes in anatomic neck of humerus, notching of articular surface of head & greater tuberosity,  & irregular new bone formation at lateral acromion;
           - in chronic rotator cuff disease, with or without tearing, there may be evidence of greater tuberosity sclerosis and spurring w/ cyst formation and subacromial spurring;


- Case Example:
    - a large 40 year old male who was felt to have isolated impingment by both clinical exam and by MRI;
    - at arthroscopy, it was found that the patient had a 2 cm supraspinatus tear which was covered by a thick layer of bursa;
    - the radiographs reveal sclerosis of the greater tuberosity and the MRI shows fluid in the subacromial bursa 

     



Optimal plain film imaging of the shoulder impingement syndrome.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, December 12, 2012 3:14 pm