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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.